HomeMy WebLinkAboutSeptic Pumping Slip - 54 CEDAR LANE 8/21/2015 ^
Commonwealth K�
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City/Town of North Andover
System Pumping Record
Form 4
`���r T{�yN0FN[y< HANDOYER
DEP has provided this form for use by local Boards ofHH�AL i| mybauned. butthe
information must be substantially the same as that provided here, Before using this fonn, check with your
local Board of Health io 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 310CyWR15.351. /
A. Facility Information
�
Important:When !
filling out forms 1. System Location:
on the computer, C.,
use only the tab
key tn move your Address ^��=--------------------- -----
cursor'uonot
use the return '`~ .. ...______
xey. City/Town State Zip Code
2. System Owner:
Name � ���'----'-------------�-----------------
Address(if different from m-------- ---------''------------ /
Cby/ToW^ �--------------- '-' ���------------ —
B~ ^Pumping Record
1- Date ofPumping ---'-----'--- 2. Quantity Pumped� --
Gallons
3. Type of system: D Cesspool(s) Septic Tank El Tight Tank Grease Trap
[]
Other(describe): ---------'----------'--'-___-__-_'-_____ --
4� Effluent Tee Filter present? Fl Yea Fl No If yes, was if cleaned? F Yea M No
5. Condition ofSystem:
u. System Pumped By: |
�
'---- ------------------- |
Vehicle License Number
Stewart' Septic
Company �--'---' --- --
7. Location where contents were disposed:
�
5tawart'e Pre-treatmen Plant, 20 So. Mill Bradford, Ma 01835
Signature ofHauler ��----'-----' --,------'--' ---Da
'
omnamremxexewjj;epaumty oate----- ------ ' ---
m��4.doc-03/06
System Pumping Record`Page I of