HomeMy WebLinkAboutSeptic Pumping Slip - 1935 SALEM STREET 1/28/2016 x.� �t !r '�ri b t41¢PA r .: �•`'y
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ystem Pu ripIng Relcdrd
Form 4'.
DER has provided this form for use by local Boards of Health. The Sy tem Pumping Record mu t
be submitted to the local Board of Health or other approving authority. DEC
6 2
A. Facility information
~--•important:
.When fining out 1. System Location:,; A3:�-5'forms on the X17
computer,use
only the tab key Address ( /?
to move your
cursor-do not City/Town St --- Zip Code
Use the return y
key.:- 2,' System,Owner:
Name
++y Address(if different from location)
City/Town State r~� Zip Code
> ��` %
Telephone Number
B. Pumping Record
,a•ti
1, Date-of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) D,6eptic Tank ❑ Tight Tank
[]' Other(describe):
Effluent Tee Filter present? ❑ Yes ❑°filo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System
1410m.,
6. Sy em Pumped By:
Name Vehicle License Number
�• . I t x �a.�.Q, �. a !rd) I
Company
7. Location where contents were disposed:
a ccd der n1a -
��
Signature of Hauler Date
http://www,mass,gov/dep/waterlapprovals/t5forms,htm#inspect
t5form4.doc-06/03 System Pumping Record-Page 1 of 1
1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER '('1UN 10 2014
System Pumping Record
dt"�Vvf`S(:ri iJ �E�NCwa�l,t�:�r�:��t.ub i
a '
HEAL V 9 pub r�sa��f
Form 4 „
i
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the i
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 from the pumping date in
accordance with 310 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, L _ `' •�`
use only the tab c �
key to move your Address
cursor-do not NORTH ANDOVER Ma
use the return City/Town State Zip Code
key.
2. System Owner:
r� CAc1--\ ❑' ICS
Name
rotwn
Address(if different from location)
City/Town State 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: �(
6. Sys tem Pumped By:
aerie° Vehicle License Number
Stewart's Septic Service
www� Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
vgnature oft trlew Date
Signature oi Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1