HomeMy WebLinkAboutSeptic Pumping Slip - 151 ROCKY BROOK ROAD 10/19/2015 Commonwealth of'Ma-, sachusetts
City/Town of North 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
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 CM R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
:
use only the tab
key to move your Address
cursor-do not
use the return North Andover
key. City/Town State Zip Code
2. System Owner:
Name
ienvn
Address(if different from location)
—------------
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date 2. Quantity Pumped: Gaglofis
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 Systeme.
5"o
6. System, Wrp- d 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 Date
-Sig—nature of Receiving Facility -6-a't-e--
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