HomeMy WebLinkAboutSeptic Pumping Slip - 203 GRANVILLE LANE 12/8/2015 . Commonwealth of Massachusetts
--- City/Town of North Andover
System Pumping Record
Forma 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 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 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
key to move your Address - ---- - -- ---- - ----... - -- _ __
cursor-do not North Andover
use the return
key. City/Town - State - - - - -
Zip Code -----
2. System Owner. ,
F
Name -- -------- ---------
relrvn
Address(if different from location) - -- --- ----- --"�-------"- ----- - ------
City/Town - -- -—-- -..
-i ----
State Zip Code
Telephone Number
B. Pumping Record
C
1. Date of Pumping 2. Quantity Pumped: --------.
Gallons
3. Type of system: ❑ Cesspool(s) Ejje6eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ----- ... --....-- -— ---------- — ..._......----- -- -
4. Effluent Tee Filter present? ❑ Yes "o If yes, was it cleaned? ❑ Yes ❑ `tdc5°
5. Condition of System:
6. System Pumpe By:
Name - - ----- -- ------
Vehicle License Number
tewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
-------------------- -
ignatureofHauler -_.-------.-._...._..... _.._-------_--_--
Date ---
_.. ..
ignature of Receiving Facility - -------- - ........ -
t5form4.doc•03/06
System Pumping Record•Page 1 of 1