HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 9/21/2016 _ C 0M n onweath Of Massachusetts
City/I—own 0-1 North Andover
ys�em Pumpong Record
Fc>rm 4
DEP haslprovided this corm for use by local Boards of Health. Other corms may be used, t
information must be substantially the same as that provided here. Before using this form, r
local Board of Health to determine the form they use. The System Pumping Record must!
the local Board of Health or other approving authority withi,; 14 days from the pumping dal
accordance with 310 CMR '15.351.
A_ Facility information
Importanu'When
SlGngoLik€om,s 1. System Location:
on the computer,
use only the tab
key to move your Address -°-
cursor-do not North Andover
use the re turn
-- _
key. City/ own —.-._.. .......... .. ....................:. .=
''�ae .i_'-..,...---•----......__.. Zip Code
2. System Owner:
Name J �.e-
—�_ G) y
Address(if di`ferent from location) —
State
7eteohone Number
B_ PUMP'ing Re6ord
7- Date of Pumping
Z-
Q
---................_ 2. Quantity Pumped:
_
Date Gallons
3- Type o'7 system: ❑ Cesspool(s) ❑ Septic Tank ❑ ;iglu T znk [:�GE
❑ Other(describe):
'�. Effluent Tee Filter present? ❑ Yes ❑ No I yes was ii ci'eaned? ❑ Yes L
5. Condition of Sysierxk-:::-- .
p
6. Systern Pumped By:
Vehicle License Number
5tewarz's Septic Service
Company -_..._.....
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mili Bradford, Ma 01835
' Signature
Date ......., -.__.._----•----
Signature o€Receiving Facii'j
t5<orrm4.00c-03106