HomeMy WebLinkAboutSeptic Pumping Slip - 453 FOREST STREET 12/8/2015 Commonweaith 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 Informati®n
Important:When
filling out forms 1. System 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 - _. _ .._.._ .
g � Zip Code
2. System Owner:
Name - -- --------- --- —-----
re+rvn '.....
Address(if different from location) -- - - ---—
City/Town --- - - -.—.—......__._ _
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ®�2 I
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 - ------------- -
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
-
Dale ---
Signature of Receiving Facility
Date .._..._. .
t5form4.doc•03/06
System Pumping Record•Page 1 of 1