HomeMy WebLinkAboutSeptic Pumping Slip - 35 WOODBERRY LANE 1/11/2016 Commonwealth of Mal ,,Sachusetts
---- City/Town of North Andover
System Pumping Record
Form 4 t
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 yo
local Board of Health to determine the form they use. The System Pumping Record must be submitted
the local Board of Health or other approving authority within 14 days from the p�mping date in
accordance with 310 CMR 15.351.
A. Facility information � a
Important:When
filling out forms 1. System Location: l <
computer,on the
use only the b
key to move your Address
cursor-do not
use the return North Andover
key. City/Town State Zip Code
2. System y Owner:
Name
Address(if different from loca#ion)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumpingat� - - --- 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:
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 of Hauler - --°- •-°— ---------
Date
ignature of Receiving Facility D - _._._._._... ...._...._.._.
Date -----
t5form4.doc•03/06
System Pumping Record•Page 1 of 1
