HomeMy WebLinkAboutSeptic Pumping Slip - 8 EVERGREEN DRIVE 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 pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab e?
key to move your Address
cursor-do not North Andover
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
Name
ieaon
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
1 Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ni_ ,,'No If yes, was it cleaned? ❑ Yes �--N-6`
5. Condition of System:
6. System P,pm ed By:
Name -,.'�" Vehicle License Number
Company—
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 Facility Date
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