HomeMy WebLinkAboutSeptic Pumping Slip - 290 BARKER STREET 12/8/2015 _ Commonwealth of Massachusetts
--- :, City/Town of North Andover
System Pumping Record
Form 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 you "!
local Board of Health to determine the form they use. The System Pumping Record must be submitted tc
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 _ 3q6
key to move your Address ----- - - -- ---
cursor-do not
use the return North Andover
-__---,-._._..-...
key. City/Town - State
Zip Code
1 y
2. System Owner:
z-r' od X51
Name ---------------- -------
reran
Address(if different from location) - ------- ---__ —_
-----__._.,.._.._....._..... .. _
State _Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 1 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: ,p
V
6. System Pumped By:
Name - -- --------- _ - -- -- - --------
Stewart's Septic Service Vehicle License Number
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