HomeMy WebLinkAboutSeptic Pumping Slip - 30 WINDKIST FARM ROAD 11/16/2015 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 pump
date in
accordance with 310 CIVIR 15.351.
A. Facility Information
important:When
filling out forms 1. System Location:
on the computer, _7>
cJ
c!)'
use only the tab
key to move your Address
cursor-do not North Andover
use the return City/Town State
key. Zip Code
2. System Owner;VQ
-v
---------------
Name
ewn
----------
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2 Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
F-1 Other(describe): —----------
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4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes F-1 No
5. Condition of System:
6. System Pumped y:
Name Vehicle License Number
rdffs Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
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Signature of Hauler Date
Signature of Receiving aclfliy- date
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