HomeMy WebLinkAboutSeptic Pumping Slip - 23 WILLOW RIDGE ROAD 12/8/2015 �
�
^
Commonwealth' cJ�� ,�� K� � �`
����RlQ0��yl\8/�/"�/u ' ,�/ /x/��������(�/ /LJsetts
��- of North Andover
City/i (�\�/[l _ .n��. `o / ^^yl`uOVer
System Pumping Record
'
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be ueed, butthe
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 opproving authority within 14 days from the pumping date in
accordance with 31OCIVIR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
nn the computer,
use only the tab
key m move your 8udr&sa
cursor-do not
North Andover
usethoxmum ----------'---- ---'--'- ' -' '-----------'--' ----------------'
key. city /own state Zip Code
2. System Owner �
Name `-~ ~-4--��-----Y----- ---'--'-----------------
------- *uumuo(�dmen:�r�m womwn------- ---'-''-------------------'-----
cityfTmwn ��-�-------------- -' - State--------'-----' Zip Code
Te|��nTmwn�r |
B. Pumping Record
1. Date ofPumping 2� Quantity ---
umm � Gallons
3. Type ofsystem: El Cesspool(s) �l/�eodoTank [l Tight Tank El Grease Trap
'
L] Other(describe): ......
-'-'------- --
4 E�uentTee Filter present? Fl Yea �l�No |f yes, was itcleaned? r-1 Yes �]1K�`
5. Condition of System:
.......... ------
6. Sy e PympedBy:
___'-__-
Vehicle License Number
Stavvart's Septic Service
'
Company ����------- -- - --
7. Location where contents were disposed: |
Stewar[e Pre-treatment Plant, 20 So. Mill Bradford, Ma01835 _______________ _
Signature n,Hauler ���------------ Date'----''--- ----'--
Signature of Receiving Facility ----- - ''-'-- ' Date----- --- — - --
t5fonn4.uo" 03/05 System Pumping Record`Page 1of1