HomeMy WebLinkAboutSeptic Pumping Slip - 7 LIBERTY STREET 2/14/20171
ED
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
TOWN OF NUR I H ANUOVER
HEALTH DEPARTM T
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 tl)zif 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:
Address
North Andover
City/Town
2. System Owner: I
— —
Name
Address (if different from location)
City/Town
State
State
177/
Zip Code
Zip Code
(Z
Teleprr ne Number
B. Pumping Record
1. Date of Pumping
3. Component: Lil Cesspool(s)
El Other (describe):
Date
4. Effluent Tee Filter present? 0 Yes
uantity Pumped:
C7")
Gallons
Septic Tank El Tight Tank 0 Grease Trap
No If yes, was it cleaned? El Yes El No
5. Observed conditi n of component pumped:
—7)
--0(2
d y:
/11-‘
Name
Stewarts Septic 58 So imball St Bradford Ma
Company
7. Location where contents were disposed:
20 s mill st bradf rd ma
ture of Hauler
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
Date
• (6
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1