HomeMy WebLinkAboutSeptic Pumping Slip - 16 BEAVER BROOK ROAD 1/11/2016 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
local Board of Health to determine the form they use. The System Pumping Record must be submiiie
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351, �r
A. Facility information JM,1, 1 �
Important:When
filling out forms 1. System Location: �)?f'le r,�I.I�i�, I� r t T���. "
on the computer,
use only the tab
key to move your Address 'J ""'- - -" ° -
cursor-do not North Andover
use the return
key. City/Town - -
State Zip Code
2. System Own v
a
Name ------.-------
ieivn i!
Address(if different from location)
Citylibwn _....--..._._.._..-.-.—.-...
State Zip Code
Telephone Number _
E3. Pumping Record
1. Date of Pumping oats ---- -"•"-- 2. Quantity Pumped: /(
Gallons
3. Type of system: ❑ Cesspool(s) r-171 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 /� —" Vehicle License Number
Stewart's Septic LService
Company - ._....- ......_ .
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of
- Date
Signature of Receiving Facili#y
Date ._..._..-" --
t5f0rm4.doc•03/06
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