HomeMy WebLinkAboutSeptic Pumping Slip - 9 TURTLE LANE 1/10/2012Commonwealth of Massachusetts
City/Town of No.Andover
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 approvingauthority within 14 days from the pumping date in
accordance with 310 CMR 15.351,
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
2. SystefrTO
Address
No Andover
City/Town
Name
Ma
State
Zip Code
ANIMIVIMAI /or.
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Address (if different from location)
City/Town
TOWN OF NORTH ANDOVER
HEN TH HEPARlagar
State
Telephone Number
B. Pumping Record
/
1. Date of Pumping L--7 4/- 2. Quantity Pumped:
Date Gallons
3. Type of system: E] Cesspool(s) ,,,,[2ptic Tank El Tight Tank 11 Grease Trap
111 Other (describe):
4, Effluent Tee Filter present? El Yes A2 1\---1 If yes, was it cleaned? 111 Yes grflo
5. Condition of System:
6, S
Name
Stewart's Septic Service
Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Pre-treatment , 0 So. Mill Bradford, Ma 01835
1/4'31 nature of Hauler
Signature of R9ceivi iT Fa lity Date
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