HomeMy WebLinkAboutSeptic Pumping Slip - 492 SHARPNERS POND ROAD 1/11/2016 ` -
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Commonwealth of Ma � sarhusetts
City/Town'� of North Andover
System Pumping Record '
Form 4
DEP has provided this form for use by local Boards ofHeabh Other forms may beusmd but the
information must be substantially the same as that provided 'ens. Before using this '--' check with `
local Board ofHea�hto determine the form they use. The System Pumping Record -��` beaubmi �
the |oca| 8oand ofHea|th orotherapproving authOhtywithin 14 days�orn tho pumpi'~~`te in ^^^
accordance vviLh31OCyNR15.351. = --
A. Facility Information=
:n � ]8N ?01A �
mUngmut forms 1. System Location:
un'the computer, 1/[�� '�/~'` �� TOVfH0FNORTUANDUVER
�eon��etab c�/ v ''/ �� �� HEALTMD�|9\�TNENT
key m move your Address
cursor'dvnot
use the return North
_-_--------- -----'�� � - -------------�
key. -,''`'~' S��- Z-1pC66e�------
2. System Owner:
Name '��-- ---- ---'-- ----------- -----
Address(if different frvm�cahon �------- -- -' '--- ---'-'----------'--
o�y�own �----------- -- - ---------------- -
B. Pumping Record
�
1, Date of Pumping _ 2. Quantity Pumped.
J� Type ofsystem: Fl Cesspool(s) Septic Tank E7 Tight Tank GreaaeTr@p
LJOther : _______'__-_`-.�___�.________ ...........
_____
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? 0 Yes No
5. Condition ofSystem:
....... ......-------
8. System Pumped By:
Stewart's Septic Service Vehicle License Number
Company �------ '-' --
T Location where contents were disposed:
Stewart's Pre-tr atment Plant, 20 So. Mill Bradford, Ma 01835
Signature mHauler -------'-- -----
Date
n�namroof�ece�ingrau|�' ' - -- - '---- ------ ----'' ----------'
' ua� --
�mnn4.doc-03m6
System Pumping Record'Page I o