HomeMy WebLinkAboutSeptic Pumping Slip - 1015 JOHNSON STREET 1/11/2016 f
Commonwealth of Ma,�sachuset$S
---- City/Town of North ,Andover
° system Pumping Record
" e< 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 submitte
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
key to move your Address
cursor-do not North Andover
use the return _--._._,_•„.....
key, ityfTown State Zip Code
2. System Owner: r,
Name
iencn
Address(if different from location) --
_._._...__._.. --—
State Zi_p Code-
B. Pumping Record
1. Date of Pumping - _ J(W:%O ,)
p g 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: I
6. System Pumped By:
c
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 - - -------
Signature of Receiving Facility
Date ._...._.._.
t5form4.doc•03/06
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