HomeMy WebLinkAboutSeptic Pumping Slip - 1077 OSGOOD STREET 8/11/2015 ..........
L of'Ma,�sachusetts
Commonwealth
11 0 01
City/Town of North Andover
System Pumpn g 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 CIVIR 15.351.
A. Facility information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab /0 7-
key to move your Address
cursor-do not
use the return North Andover .. ........... .......
key. CityfTown State Zip Code
2. System Owner:
Name
ninon
Address(if different from io`catior)___
City/Town S.tate Zip...Code
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was ifclbaned? ❑ Yes ❑ No
5. Condition of System:
6. 'System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
Signature of Hauler Da.te --------
Signature of Receiving Facility b-at-e-
t5form4.doc-03/06 System Pumping Record•Page 1 of 1