HomeMy WebLinkAboutSeptic Pumping Slip - 316 RALEIGH TAVERN LANE 8/12/2015 D
Commonwealth 6f'Ma8sachusetts C F,
City/Town of North Andover
System Pumping Record FOV�`
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 15351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 3
use only the tab L,
key to move your Address
cursor-do not
use the return North Andover
key. City/Town State Zip Code
2. System Owner:
remm
Address(if different from
—------------
CityfTown State Zip Code
Telephone Numbe r
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 it-cleaned? r_1 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 Date
t5form4.doc-03/06
System Pumping Record•Page 1 of 1