HomeMy WebLinkAboutSeptic Pumping Slip - 210 RALEIGH TAVERN LANE 8/27/2015 Commonwealth 6f Ma8sachus
City/Town of Noah Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the 1
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 15.351.
A. Facility information
Important:When
filling out forms 1. System Location:
on the computer, I
use only the tab 71rr� �j� I ��_ '
key to move your Address
� - ----.. . - --._... -- ---- -
cursor-do not
use the return North Andover
-----...___.. ........... ..__...
key. City/Town State Zip Code
2. System Owner: E
'co
Name _. ...__..._._... .
ienvn
- ---- ...._................._.. ... ...,._._.._.._..,.- - - -----------.-...-..---- -- ---
Address(if different from location) - --
City/Town State Zip Code
Telephone Number
. Pumping Record
1. Date of Pum in 2 -� _ �6
p g Date - _.__..-.--- 2. Quantity Pumped:
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? ❑ Yes ❑ No
5. Condition of System:
1�)
6. System Pumped By:
Name _ 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
Signature of Hauler Date --
.._..---.._._..._..._.......--- .._..._. _.._
ignature of Receiving Facility Date ----
t5form4.doc•03/06
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