HomeMy WebLinkAboutSeptic Pumping Slip - 115 CRICKET LANE 8/13/2015 . - - '
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Form 4 )OY HCF NOP�HxUDOVER
DEP has provided this form for use by boa| 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
|000| Board of Health to determine the form they us*. 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 310CPWR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
the enompu te r, ��
use only the�b
key oo move your addmvn -------- - --'
cursor'dnnot
North Andover�emo��� __.
key, City/Town - - -' '----------- -------------'---
State Zip Code
2. System Owner
wame �---------------------'-------------------
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Address(if different from locationj--------'— --........ ----''------'----'-- �
CityrFuwn ��------'----'--- '- �tate---------�--- --Zi
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
-- ----'
3. Type of system: El Cesspool(s) r� Septic Tank [j Tight Tank El Grease Trap
L] Other(describe)-. -----'-'-------------------------'---- --
4. Effluent Tee Filter present? [I Yes F� No If yes, was it cleaned? F-1 Yes [_1 No
5. Condition of System:
O. System Pumped By:
wame ���---------- --------'-'---'-----'------------------ �
Vehicle License Number
Stewart's Septic Service
Company ��--------- --' ''- -
T. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
SignameofHau�r ��--------'------ --------'-- -----
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mmrm*�c-03/06 System Pumping Record-Page 1 of 1