HomeMy WebLinkAboutSeptic Pumping Slip - 53 OLD CART WAY 11/16/2015 '
- ^
^
'
�
Commonwealth mfMa � sachu
City/Town of North Andover
over
~
Pumping
System ec��rd '
`
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may beused but the
information must besubstanhaUy the same aa that prov�ed here' Bafbos 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 mr other approving authority within 14 days from the pumping d'te in
accordance with 31OC�WR15.351, ~ -
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 17 , /-� ~'�- NOV 1 R
uenn��e�h .`°v ' ° ~
key m move your ---'---==�-----'-----------
»«m» -domd N»�hAnd
m�U�mmm ~~,"' ___ ------- ------
xey. City/Town State Zip Code �� ----
2. System Owner: 4 &
Name ^~ u
Address(if different from m(---------'- -----'-'--'-------------' --
Cty�vwn __------------- -- - --��--'----'--'------ -------
T�----- —be r—
B. ~~��u00^�Un� Record �---
|
A") �����
1. �� �Pum�� -- 2� ���� pump�� /��^�
3. Type ofsystem: [l (a) Septic Tank Fl Tight Tank Fl Grease Trap
LJ Other :
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? El Yes n No
5. Condition ofSystem:
O. System Pumped
m~' ~ v—eh-�—�--L-m-a-n—oe'-Number
----'--
���-----
Company �------- - --- '—
/. Location where contents were disposed: �
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, MoU1835_____________
Signature ofHauler Da------.......
'--' ------
S�namremReneivinQFao|t...... —'-- ���.---- ---' — ----------------
mmnn4.um,03m6
System Pumping Record^Page 1of1