HomeMy WebLinkAboutSeptic Pumping Slip - 88 ROCKY BROOK ROAD 10/19/2015 . �
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Commonwealth mf'Ma,� achuse+t `
City/Town of North &^nr
Cver
�� ^ Record
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System o �K���U�� m*��K�u �
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be uaed, butthe
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 besubmitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CW1R 15.351.
A. Facility Information
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Important:When
filling out forms 1. System Location:
vn the computer,
use only the tab
key m move your *ddman / ---------------------' -------------------
oumo,'do not
North Andover
use�e�mm -------- ---'--'- ' -_-___-____-_- ...... __--
key. C/ov/mwn State Zip Code
2. System Owner:
Name ^ ' ^ -���-'------'-------'-----------
-------
Add msn(if dnferent from oomUnn -------------'—'---------------'-
City/Town ���-------'------- '- State------------' — Code
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-- --'
/elephwn=wumuer |
B. Pumping Record
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1. Date ofPumping -------�'���-ac- 2 Quantity Pumped: --- �
Date � 6a|loma
3. Type of system: Fl (s) Septic Tank [] Tight Tank El Grease Trap
E] Other(describe): -------'------------'-----------'-'------ --
4. Effluent Tee Filter present? F Yes Fl No If yes, was it cleaned? R Yes E] No
5. Condition ofSystem:
5. System Pumped By:
Name ' ' - ��� ------ '-------------------- �
Vehicle License Number
Stewart' Septic Service
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Company ���---'---- --' --
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, MaO18%}5 _______________ _
Signature ufHauler ����--------'------ ���-------- ------
8ynomrenfReoeivinoFacility ----- --- '----' Date-�--- ---''-- -
t5fmm �c-03/06 System Pumping Record-Page 1 of 1