HomeMy WebLinkAboutSeptic Pumping Slip - 10 HAWKINS LANE 2/14/2017Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
EVE
IT11 L' ?„,017
TOWN OF NORTH ,OVER
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
Important: When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
Address
, ) .A<n
Aos (
North Andover
City/Town
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Component:
111 Other (describe):
4. Effluent Tee Filter present? Ell Yes 111 No
5. Observed condition of component pumped:
State
Zip Code
State':& ) Zip Code _
Telephone Number
Date 2.AtIlantity Pumped:
Cesspool(s) aSeptic Tank 111 Tight Tank
6. Systein Pumped -By:.
/fr./ /
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7, Location where contents were disposed:
20 o mill st bradford ma
Sinature of Hauler
Signature of Receiving Facility (or attach facility receipt)
Gallons
111 Grease Trap
If yes, was it cleaned? la -Yes II] No
Vehicle License Number
Date
t5form4.doc• 11112
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