HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 2/14/2017 (4)Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping ecord
Form 4
FEB 1 4 Z017
TOWN OF NOKIH ANDOVER
HEALTH DEPARTMENT
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
1. System Location:
11\, 0 to
...-
Address
North Andover
City/Town
2. System Owner:
ak-C
Name
Address (if different from location)
City/Town
State
State
Telephone Number
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping
3. Component:
3-1-
Date
2. Quantity Pumped:
111 Cesspool(s) I: Septic Tank
111 Other (describe):
LI Tight Tank
4. Effluent Tee Filter present? El Yes 111 No
5. Observed c ndition of component pumped:
Gallons
[3-'
ease Trap
If yes, was it cleaned? El Yes El No
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Lo?tionber95ntents were disposed:
adford ma
nature of Hauler
Vehicle License Number
' nature of Receiving Facility (or attach facility receipt)
Date
Date
t5form4.doc• 11/12
System Pumping Record • Page 1 of 1