HomeMy WebLinkAboutSeptic Pumping Slip - 142 DUNCAN DRIVE 1/11/2016 Commonwealth of Massachusetts
---- City/Town of forth 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 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 Informati®n
important:When
filling out forms 1, System Location:
on the computer, , ?
use only the tab
key to move your Address
cursor-do not use the return North Andover —_—_—
key. City/Town – State i f.W� )( rr , i;i '�),'Zip Code
2. System Owner: r
Name
rewn
Address(if different from location) ---- '-""----- "- -- - -----•--
---•-----._....._..
State Zi-p Code
- Telephone Number
B. Pumping Record
1. Date of Pumping Date� 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:
..fir.
6. System Pumped By: µ .. . >
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 ---._...__...___..__. .._._. . ...._..---.•-------__---- ,
Dale
ignature of Receiving Facility D
ate
t5form4.doc•03/06
System Pumping Record•Page 1 of 1