HomeMy WebLinkAboutSeptic Pumping Slip - 511 WINTER STREET 11/16/2015 1
Commonwealth of Massachusetts t
x _ City/Town of North Andover
System u pan Record
Form 4-
i.^M
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 farm, 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
key to move your Address
cursor-do not North Andover
use the return — ----- --- --- -
-- -- _- - — ----
y City/Town - State
2. System Owner:
rab
Name
ENA
Address(if different from location)
City/Town State Zip Code
Telephone Number - -- -Pumping Record
Record
- . ! x;
1. Date of Pumping gate 2. Quantity Pumped: 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 it cleaned? ❑ Yes ❑ No
5. Condition of System: i
r
6. System Pumped By:
Name Vehicle License Number
Stewart'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
I
Signature of Receiving Facility Date
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