HomeMy WebLinkAboutSeptic Pumping Slip - 61 WHITE BIRCH LANE 12/15/2015 Commonwealth of Massachusetts
City/Town of ' .�...
System Pumping Record <
Facility Information:
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System Location:
Address
City/Town State Zip Code
I
System Owner:
Name:
b ,
location of pump)
ress i i -erent from
City/Town State Zip Code
C'
Telephone Number
Pumping Record
Date ofPumping Quantity Pumped 360 gallons
Type of System //Septic Tank Grease Trap Other (what)
System Pumped by:_
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Company: ROOTER-MAN 12 East Dracut Rd., Methuen,MA 01844
Location where contents were disposed:
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Signature of Hauler � . ,� . Date
Commonwealth Of Massachusetts
Cityjown of No Andover J 10 01
System Pumping Record TOWN OF NOR'T"1 ANDOVER
Fora' 4 L. rkq DEPAR''rn" ENT
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 use only he tab C
key to move our Address
cursor-do not No andover
use the return Ma
key. City/Town State
Zip Code
Q 2. System Owner:
Name
r�tn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping cor
1, Date of Pumping Date Quantity Pumped: --
lans
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sys m:
6. System Pum By:
Name Vehicle License Number
Stewart's Septic Service
Company
r, 2
7. Location where contents were disposed:
Stewart's Pre-treatment Plant 20 So. Will Bradford Ma 01635
Signat a fHauler Date
Ign re of eceiving Facility Date
t5form4,doc•03/06 System Pumping Record•Page 1 of 1
a ri i'
Commonwealth of Massac husetts
---, City/Town of forth Andover
System Pumping Record
Form 4
used but the
DEP has provided this form for use by IocaB tflati of
ovided here. Before using this form, check with your
information must be substantially the same p Record must be submitted to
local Board of Health Health determine the
they use, The System
authority within 14 day fromntthe pumping date in
the local Board of He
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 Ma 01886
cursor-do not North Andover Zip Code
City/Town
use the return State
key.
2. System Owner: ti
�^ Name
Q nmm
Address(if different from location)
State Zip Code
City/Town
Telephone Number
B. Pumping Record
C .-
1. Date of Pumping Date 2. Quantity Pumped: Gallons
T ❑
Tight Tank Grease Trap
Septic Tank ❑ 9
. 3. Type of system: E] Cesspool(s) p
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
If.yes, was it clearied? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Date
Signature of Receiving Facility
Date
System Pumping Record•Page 1 0
t5form4.doc•03/06