HomeMy WebLinkAboutSeptic Pumping Slip - 142 ABBOTT STREET 12/8/2015 Commonwealth of Massachusetts
--- . City/Town of North Andover
System Pumpong 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 informati®n
Important:When
filling out forms 1. System Location:
on the computer, I V
use only the tab /J 4
key to move your Address - —
cursor-do not North Andover
use the return --__—_,..___.____ _
key. City/Town State-— "
Zip Code
ti
2. System Owner: r
Name
rerron
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Rec'ord'
1. Date of Pumping vC�
Date - - -- 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:
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 --
_ .... _.
Signature of Receiving Facility � � � -- - --
t5forrn4.doc•03/06
System Pumping Record•Page 1 of 1