HomeMy WebLinkAboutSeptic Pumping Slip - 733 TURNPIKE STREET 1/19/2016 (3) Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
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 your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days fry:! T be' Our'" h" date in
accordance with 310 CMR 15.351.
are
A. Facility Information
Important:
When filling out 1. System Location.-
forms on the w Y /
computer,use
only the tab key CityfTown Addre
to move your i Slate Zip Code
�j /
cursor-do not _._.. _
use the return
key. 2 System Owrjer:
Name �+
. Address(if different from location)
Citylrown — -- Stale Zip Code
Telephone Number —
B. Pumping Record
1. Date of Pumping -- -� - 2. Quantity Pumped:
Date 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:
STEWARTS SEPTIC SERVICE
6. System Pumped By: 58 SOUTH KIMBALL ST
Wind River Environmental RADFORD,._MA.®1-835--
Name cI63 WeAft-Avg. _ —
v74,71
--__._..-.iGl0UMter-b"01930 . .
Company
7. Location where contents were disposed
Signature of Hauler Date !
Signature of Receiving Facility Date
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