HomeMy WebLinkAboutSEPTIC PUMPING SLIPS Commonwealth Of Ma8s chusetts
----- w City/Town Of North Andover
yt, m 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 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 CMR 15.351.
o;,
A. Facility Information
Important:"'When
filling out forms 1. System Location: 1
on the computer, � �
use only the tab a
i
key to move your Address /- - --
cursor-do not North Andover
use the return __.,.....
/Town
Cit
key. Y State Zip Code
2. System Owner: A 1
Name -
ietrrun
Address(if different from location) - —
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -Da 2. Quantit y Pumped:
Ga ons
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 - --L- ---....
P� Vehicl--e icense_--- Number_------
ewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
ignature of Hauler D__._al._,.._--..__._..._
e
ignature of Receiving Facility Date ....... . . .....
t5form4.doc•03/06
System Pumping Record•Page 1 of 1
=
Commonwealth of Massachusetts
City/Town of No Andover
IV
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 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 CIVIR 15.351.
A.` Facility Information
/mportancwm,n
filling out forms 1. System Location:
on the computer,
use only the tab
key�move your �
am�u 'du"ot
~~ NoAnd
use�e�mm ",e' ma
key. uv"/»"» State Zip Code
2. System Owner:
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
l. Date of Pumping 2. Quantity Pumped:
Gallons
` 3 Type ofsystem: Fl Cesspool(s) Fl Septic Tank El Tight Tank El Grease Trap
Fl Other(describe): |
4 Effluent Tee Filter present? Fl Yes Fl No K yes, was itc|e" ed? El Yes M No
5. Condition ofSystem: \
/ |
6� System Pumped
Name Vehicle License Number
Stewart's Septic Service
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. mill Bradford, Ma 01835
Signature'xHauler �-------- �
-
'
Signature o*Receiving Facility Date �
t5fonn4.u*c-03m6
System Pumping Record`Page 1uv1
.mJ
Commonwealth of Massachusetts
J
W City/Town of No Andover !,"Y "' '� ,1'
System umpire ee .rd
or
rY1 .,'
„M w.
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 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 z–/ C —
key to move your Address
cursor-do not No andover Ma _
use the return Cit frown State Zip Code
key. y
2. System Owner:
Q
._4 - -
Name
--
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date l 2. Quantity Pumped: Gallons —
3. Type of system: ❑ Cesspool(s) 2-9-e'ptic 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:
— J U
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 Q1835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record o Page 1 of 1