HomeMy WebLinkAboutSeptic Pumping Slip - 1267 OSGOOD STREET 11/16/2015 Commonwealth of Ma,-tsachusetts
City/Town of North Andover
System Pumping Record
0 Form 4
DEP has provided this form for use by local Boards of Health. Other f b d but the
a 2, C
information must be substantially the same as that provided "T-66, check with your
local Board of Health to determine the form they use. The System Pdhioindoe�lbird' I 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 )'_" 6 ()�-S 6
key to move your Address
cursor-do not North Andover
use the return
ty/Town State Zip
key. Ci Code
VQ2. System Owner:
TU
Name
tenon
Address(if different from location)
---—---------------------
City/Town State Zip Code
Tele—Ph;—r'"—Um—ber---------
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 F-1 No If yes, was if cleaned? ❑ Yes ❑ No
5. Condition of System:
6.,—qystem Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
'.StOW"art's P reatment Plant, 20 So. Mill Bradford, Ma 01835
Date
„wgr�ert rte of Hauler —--—----------- ------
Signature of Receiving Facility Date
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