HomeMy WebLinkAboutSeptic Pumping Slip - 43 OXBOW CIRCLE 10/19/2015 Commonwealth of'Ma8sachusetts
City/-Town of North Andover
System Pumping ecord
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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location: _
on the comp ,
use only the tab - �4jc_4j
key to move your Address
cursor-do not North Andover
use the return — — -----....- - --- — --- -. ------ ---
key. City/Town State Zip Code
2. System Owner: F
r
-
Name
ienvn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -- l - - 2. Quantity Pumped: - --- -
Date Gallons
3. Type of system: ❑ Cesspool(s) ] Septic Tank ❑ Tight Tank ❑ Grease Trap
r
❑ Other(describe): ---- --...- -- ...---— -- ---- - - ..........
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Purn0`ed_1IB
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
Signature of Receiving Facility Date
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