HomeMy WebLinkAboutSeptic Pumping Slip - 303 BERRY STREET 11/16/2015 -
°
ICN Commonwealth m� K8 � �
�������]�]�]\8/��x�/v ' ��/ /v.��������(�/ /Ljsetts
City/Town of North Andover
]ver
���s* �����'�.�_� �Record- `���
Form 4
DEP has provided this form for use bv local Boards of Health. Other forms may be used, but the
information must be substantially the same ea that provided here. Before using this form, check with your
|000| Board of Health ho 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 310CKAR15.351.
A. Facility Information
Important:When 1. System Location:
filling out forms on the computer,
use only the tab
key tn move your Address
cursor-do not —
North Andover
usethe return -------------- ------- - --------------- --- -------------------
key. City/Town State Zip Code
2. System Owner: �
VQ Name ^
^---�--~
Address different from location) ----------------'-----
-------- --
City/Town -- �City/Town//o�n State Zip Code
Telephone Number
|
B. Pumping
1. DutaofPumping Date --- 2� Qumnd� Pumped� Gallons
3. Type ofsystem: El Cesspool(s) 14 Septic Tank El Tight Tank 0 Grease Trap �
El Other(describe): ---------------------'------------------' --
4. Effluent Tee Filter present? Fl Yes F No If yes, was it cleaned? E] #m E] No
5. Condition of System-.
8. System Pumped By:
Name Vehicle License Number --- �
Stewart' Septic Service
Company � ����—'-------'-------
7. Location where contents were disposed: �
Stewar[s Pre-treatment Plant, 20 So. k8i|| Bradford, Ma
SignatvmofHauler �-----'------- Da�-------- .. —
---------------------
Signature nf Receiving Facility---'-- ---'—'--- Date---------'-- ----
mmnn4.um,03/00 System Pumping Record^Page 1uf1