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HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 12/8/2015 (3) 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 511ing 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 _ _ y State Zip Code 2. System Owner: ke- ( Name -- ienon ,....,.,. Address(if different from location) - "- --- ---"-"'-------- -°-°--------•---- ----- State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping g Dat - in p 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 Signature of Hauler ----- " Signature of Receiving Facility Date ------ t5form4.doc•03/06 System Pumping Record•Page 1 of 1