HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 5/30/2017 (2) Commonwealth of Massachusetts
w City/Town of North Andover
ry System Pumping Record
t
Form 4
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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. rn
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A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only he tab '
key to move your Address
cursor-do not North Andover
use the return - —
key. City/Town State Zip Code
2. System Owner:
rob
Name
Ielrarn
Address(if different from location)
......... - — -
City/Town State Zip Code
---u._ ._...-___... p_..___�Number ......
Tele h ----one Nu Y—_--
B. Pumping Record
1. Date of Pumping ( 2Date . Quantity Pumped: Galloh ----
3. Component: ❑ Cesspool(s) ❑cSpptic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe):
® )4� —
TA
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ® No
5. Observe condition of component pumped:
.,
ystef Pumped .y
Ile
-
me Vehicle License Number
S ewarts optic 58 So Kimball St Bradford Ma
Company
Location where contents were disposed:
o mi�bradford ma
S1 ure of Hauler - Date
Sictlature of Receiving Facility(or attach facility receipt) Date
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