HomeMy WebLinkAboutSeptic Pumping Slip - 1100 SALEM STREET 1/11/2016 1
Commonwealth of Ma, sachusotts
--- . 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
r
filling out forms 1. System Location:
on the computer,
use only the tab 0 c) (` / °; JAN
key to move your Address
cursor-do not North Andover i J'l�i` >(�
use the return --____. ._._.... __
Ci /Town .. ......... ......— - -- fe1�-.#,-!L�....:`_i k!
key. ty Stag Zip Code
2. System Owner: {
—–---- – -
Name -....__,.._ .... .._....__._.____
ieavn
Address(if different from location)
------._...._.. _...----------------._.--°------ ..--
City/Town State Zip Code
Telephone Number —
Pumping Record
1. Date of Pumping P g Date �----------.... ....__. 2. Quantity Pumped: -- ------
Gallons
3. Type of system: ❑ Cesspool(s) L4 Septic Tank ❑ 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:
6. System Pumped By:
Paq__
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
------...--- -_-------- _...__.__..__..._. .._... _..------ --
Signature of Hauler Date ---
- _.. _
Signature of Receiving Facility Date
t5form4.doc•03/06
System Pumping Record•Page 1 of 1