HomeMy WebLinkAboutSeptic Pumping Slip - 115 SUTTON HILL 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 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
filling out forms 1. System Location
on the computer, {
use only the tab 'r '1 , (.. —=J - __.... f, �' f L°
key to move your Address _..-- --
cursor-do not North Andover
use the return
key. City/Town --• - -----
Y State , Zip Code --
2. System Ow r:
. (
Name _..... .._....--
a�tvn
- --.-_......_....._......_..__.._...... - ------------------ -------
Address(if different from location) --
City/Town - State Zip Code
Telephone
B. Pumping Record //1. Date of Pumping Date - 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) [:�6"ptic 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 Service
Company ---
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature ---._..---- _---
Date ---
Signature of Receiving Facility
Date ._..._. .—
t5form4.doc•03/06
System Pumping Record•Page 1 of 1