HomeMy WebLinkAboutSeptic Pumping Slip - 2189 SALEM STREET 11/16/2015 Commonwealth of-Ma sachusottS
�ity/Town of North Andover
System Pumping cord
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
computer,
use only he tab
fillip out forms System Location:
on the key to move your Address
cursor-do not North Andover
use the return ---
key. Cityfrown State — - Zip Code
."
2. System Owner: e '
m
Name
iencn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - - - 2. Quantity Pumped:
--- -—
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ---- - ... —-...— -— ---- _ ----
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was if cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Purhped By, '
Y'`,,
Nam Vehicle License Number
�S�e e„�.
w.
art'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
------Facil------ .._..- _._.._..-. .. ....__..._.. ----
Signature of Receiving ity Date
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