HomeMy WebLinkAboutSeptic Pumping Slip - 21 SOUTH CROSS ROAD 2/14/2017Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
FEB 4 ?il i
TOWN or NOtt I hi 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
1.
System Location:
-
Address
North Andover
City/Town
2. System Owner:
naonc,
Name
Address (if different from location)
City/Town
State Zip Code
State
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
Date
11 Cesspool(s)
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes 0 No
5. Observed condition of componei, t pumped:
6. Sy.te1i Pumped' By:
/1•-,
Name
SC) •
•:-Quantity Pumped:
Gallons
eptic Tank 0 Tight Tank LI Grease Trap
Stewarts Septic 58 So Kimbal St Bradford Ma
Company
7. Location where contents were disposed:
2 so mill st bradf rd ma
Sign ture of Haul
re of Receiving Facility (or attach facility receipt)
If yes, was it cleaned? 0 Yes 0 No
Vehicle License Number
Date
t5form4.doc• 11/12
System Pumping Record • Page 1 of 1