HomeMy WebLinkAboutSeptic Pumping Slip - 288 FOSTER STREET 2/14/2017Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
ECE1VED
FEB 14 7017
TOWN OF NORI H 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
Important: W hen
filling out forms 1.
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
System Location:
gg FOSitT
Address
North Andover
City/Town
2. System Owner:
Name
State
ct
Zip Code
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
3. Component: Elil Cesspool(s) Ig--5eptic Tank El Tight Tank
El Other (describe):
4. Effluent Tee Filter present? Ej Yes LI No
5. Observed cond' (on of component pumped:
Stewarts Septic 58 So Kimball St Bradford Ma
Company
Location where contents were disposed:
2 I st bradford ma
Gallons
Ell Grease Trap
If yes, was it cleaned? El Yes 11] No
Vehicle License Number
Sh ure of Hauler
Signature of Receiving Facility (or attach facility receipt)
1-5-n
Date
Date
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