HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 3/16/2017 (4)Important: When
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,an
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4 TOWN OF NC)Ri 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.
CE VED
AR e 201
A. Facility Information
1. System Location:
31:727) \ 3 ,5)
Address
cixr
Cityfrown State Zip Code
2. System Owner:
Name
Address (if different from ocation)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
Gallons
3. Component: LI Cesspool(s) El Septic Tank El Tight Tank II Grease Trap
Er -other (describe):
4. Effluent Tee Filter present? II] Yes [11 No
5. Observed condition of component pumped:
ystem7pumped :
--- -
,.—
Sie-vvarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
st bradford ma
-"'
L
Si n t.r of Hauler
ignature of Receiving Facility (or attach facility receipt)
If yes, was it cleaned? LI Yes El No
Vehicle License Number
Date
Date
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System Pumping Record • Page 1 of 1