HomeMy WebLinkAboutSeptic Pumping Slip - 571 SHARPNERS POND ROAD 3/16/2017Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
RECEWE
MA
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TOWN OF NORTH 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: When
filling out forms 1.
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key
System Location
Address ,s
City/Town
2. System Owner:
art-) r\c,
Name - -
Addross (if different from location)
State
Zip Code
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
Date
11] Cesspool(s)
111 Other (describe):
4. Effluent Tee Filter present? 111 Yes III
5. Obse
C'
2. Quantity Pumped:
Gallons
Septic Tank 111 Tight Tank D Grease Trap
No If yes, was it cleaned? Ill Yes No
edi condition of component pumped:
6. System Pumpect„By.;.--
tewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
ature of Hauler
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
Date
t5form4.doc• 11/12
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