HomeMy WebLinkAboutSeptic Pumping Slip - 62 STONECLEAVE ROAD 1/23/2018 Commonwealth of Massachusetts
City/Town of North Andover
7
-
System to i 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 1
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.
A. Facility Information
Important.When
filling out forms 1. System Location
on the computer, — � �
use only the tab .._
key to move your Address
cursor-do not north andover Ma
use the return -- - —
key. City/Town State Zip Code
2. System Owner:
tab
Name
mum
Address(if different from location)
north andover
City/Town State Zip Code
Telephone Number
. Pumping Record .--,
1. Date of Pumping 4`") - 2. Quantity Pumped: 000
Date Gallons
3. Type of system: ❑ Cesspool(s) le Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): 111...1------ ...-....... _.
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System: '
--- — - ---- .........
6. System Pumped By:
---- - ---.....
Name Vehicle License Number
Stewart's Septic Service
Company r
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 _
Signature of Mauler Date
Q.j
.._...
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
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YV°P/�,q, W',drDEP has provided this form for use by local Boards of Health. T i � ao d must
be submitted tc+the local Board of Health or other approving cutp � ,
.A: Facility Information
Important
�,;,.yUhan friUng out• 7 r..,..System Location, .
"CtNTipUter,Us+9, r ,:�• n� �. ,l � �� ,�
only the tab key Address t
to move your,
cursor-do pot
use the retum City/Town 4 r, Ste Zip Code
II. �
'" ��' •
1 2 System Owner, ,: r
;. Name 4
low
,. Address(If different from location)
City/rown State 7 Zip Code
«. "
Telephone Number
` 4j .rry BSA f U In
mp g Record
. 1' '.Date of Pumping Det/ 2. Quantity Pumped; 6
Gallons
3� pa of systems ❑ Cesspaol(s) , ' Septic`tank ❑ Tight Tank
❑'Other(describe},
4 Effluent Tee Filter present? Yes l y as It cleaned? Yes
• ❑ fes, w
'
r f S ,Co�ditlon of System;
6, Sy em pumped Byt ,
f 11
CJ
am® Jj��V�Jehh/icle License Number
. .� [/J� - '"Jf'' 1 Y1(/1
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Compapy
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7, Location where contents Vrere d1;3posed:
ma1
signature of Hauler;;br ��.• Date
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