HomeMy WebLinkAboutSeptic Pumping Slip - 128 JOHNSON 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 yot
local Board of Health to determine the form they use. The System Pumping Record must be submitted t
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 12-k- ` ek
key to move your Address _l �._._. � '-- –--- --- -... -_-._... . .._. ----------
cursor-do not
use the return North Andover
—___--.-__.._•...._ _
key. City/Town State – ...
Zip Code
2. System Owner:
Name _..... .. ._...-- ---- -- - --- ------
Address(if different from location)
-----
State Zi p Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
V -------
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:
ZNameVehicle License Number
art's S tic 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
Date ........._
t5form4.doc•03/06
System Pumping Record•Page 1 of 1