HomeMy WebLinkAboutSeptic Pumping Slip - 21 APPLETON STREET 10/19/2015 ^ �
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Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, 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 be submitted to
the |uco| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCyNR15.35l.
A. Facility UU0fm^rmat-oY0
important:When
filling out forms 1. System Location:
on the computer,
use only the tab �_________________________
key m move your mmeon '
cursor-do not
North Andover
use the return
----'-----'---- --- '-- - - ------------'-- -----------'-------
key. City/Town State Zip Code
Z GysbamOwner:
__ ___________
Name WC44
~--~�--~
Address(if different from location)
----- ---- -- ''----' ----------------'-----
City/Town State Zip Code
Telephone Number
B. Pumping Reco rd
1. Date of Pumping
Date 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) V Septic Tank E] Tight Tank E] Grease Trap
M Other(describe): ------------------------------------ --
4. Effluent Tee Filter present? D Yes Fl No If yee, was if cleaned? E] Yes E] No
5 Condition VfSystem:
................... '��
Name Vehicle License lNumber
--
� Stewart's Septic Service
Company �������-------- --- '— �
7. Location where contents were disposed:
Steweryn Pre-treatment Plant, 20 So. Mill Bradford,_MaU1835 ____________________________
Signature nfHauler ���-'---------'- Date'-----'''-' - ------------'-------
SiRnature of�e&iiiving--cifity Date'-'------- - '-'--------------
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