HomeMy WebLinkAboutSeptic Pumping Slip - 95 CAMPBELL ROAD 8/15/2017 Commonwealth of Massachusetts
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X� City/Town of North Andover
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System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
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A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, i
use only the tab _ -- --- {1 I i 1
key to move your Address
cursor-do not North Andover Ma 01845
use the return ......--- .........
key. City/Town State Zip Cade
0 2. System Owner: ,
Name —
/&MR
Address(if different from location)
Citylfown State Zip Code
Telephone Number
B. Pumping Record
/ C ._
1. Date of Pumping Date 2. Quantity Pumped. Gallons
3. Type of system: ❑ Cesspool(s) Vflz Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - --
4, Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
C. y tem Pumped By:
.........-.........--- -- - ------------
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
i
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
°.,...
Signature of Ha filer Date
- � .
Signature of eceiving Facility Date
t5form4.doc-03/06 System Pumping Record•Page I of 1
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