HomeMy WebLinkAboutSeptic Pumping Slip - 47 BOXFORD STREET 1/11/2016 Commonwealth of Massachusetts
---- w 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
local Board of Health to determine the form they use. The System Pumping Record must be submiiLe
the local Board of Health or other approving authority within 14 d2 "frg tti�"piarn �ing date in
accordance with 310 CMR 15.351.
A. Facility information
Important:When
filling
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the tab
out forms System LOC
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key to move your Address — -.-.__......._..---_•-_.-_-"_-" "----.,__--. __-•-
cursor-do not North Andover
use the return — _--,-_,_,•_..•
key. ityfTown State Zip Code
2. System Own r:
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_ r.. G1 -- -. .._.....__ .
Name _.... . .....-- ------------------.-------
Address(if different from location)
----- ._....._..__...._..,.... -...----....._.._..-.—.—.----- ---
City/Town � State Zip Code
Telephone Number B. Pumping Record
1. Date of Pumping --- - - 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 cl'eanad? ❑ Yes ❑ No
5. Condition of System:
- w
6. System Pum .c By.
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
Date
Signature of Receiving Facility � �-'�
Date
t5form4.doc•03/06
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