HomeMy WebLinkAboutSeptic Pumping Slip - 361 CHICKERING ROAD 11/16/2015 Commonwealth of Ma,sochusotts
--- . City/Town of North Andover
System u purr Record 1
Forma 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 forms y S em..�,
Location:�
on the computer,
use only the tab
key to move your Address
cursor-do not North Andover _
use the return
key. -----
City/Town State ip tCode
2. System Owner: �b
Name
rewn
Address(if different from location)
City/Town State Zip Code
Telephone Number
—.Pumping Record
1. Date of Pumping � - —.._.. .._ 2. Quantit y Pum p ed:
Date
-- -—
Gallons
3. Type of system: ❑ Cesspool(s) "Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes NNo If yes, was it cleaned? ❑ Yes ❑ o
5. Condition of System:
. .
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
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1