HomeMy WebLinkAboutSeptic Pumping Slip - 23 GILMAN LANE 1/11/2016 Commonwealth Of` Massachusetts
---- City/Town of North Andover
I
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 I
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 Wormati®n
lmportant:'When
filling out forms 1. System Location:
on the computer,
use only the tab Z3 f
key to move your Address - - -_.-_.-_,___
cursor-do not North Andover
use the return —
key. City/Town
State F� Zip Code
2. System Owner: r,
Name
iewm
----
Address(if different from location) --
City/Town State Zip Code
Telephone Number _
B. Pumping Record
1. Date of Pumping --- - --- -- - -•.
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:
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 —
' pale
Signature of Receiving Facility ` ' .6.a.te
._...._.._ _—
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