HomeMy WebLinkAboutSeptic Pumping Slip - 705 MIDDLETON 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 ��
key to move your Address -
cursor-do not
use the return North Andover
—___--.-.___..._-__. _
key. Cityrrown State - ..
Zip Code
I 2. System Owner: ' r)
- !
Name G� - -- - -- -------- - - ------
Address(if different from location) - "----- `-"------- ----------------
City/Town ---- - -- ---.—.._...
- State Zip Code
- Telephone Number •
B. Pumping Record
1. Date of Pumping Date t 2. Quantity Pumped: ------
Gallons
3. Type of system: ❑ Cesspool(s) L1�1• Septic Tank
El Tight Tank El Grease Trap
❑ Other(describe): ---- - ... — ------ -- ..
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
(���(,0
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
-
Da ie ---
Signature of Receiving Facility
Date ._._._.._.
t5form4.doc•03/06
System Pumping Record •Page 1 of 1