HomeMy WebLinkAboutSeptic Pumping Slip - 199 OLD CART WAY 5/30/2017 Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
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 pumpi �1
.9te in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Locat,
on the computer,
use only the tab qq
key to move your Address
cursor-do not
use the return ............ ..............
key. Cit awn State Zip Code
2. System
------------------------ ......
Name
ratan
Address(if different from location)
------------
City/Town State Zip Code
Telephone Number
B. Pumping Record
-----------
2 Quantity Pumped: t.
1. Date of Pumping Date Gallons
3. Component: F-1 Cesspool(s) eptic Tank [I Tight Tank El Grease Trap
El Other(describe): --------- ... ..................
4. Effluent Tee Filter present? El YesNo If yes, was it cleaned? El Yes El No
5. Observed condition of component pump d:
----------- -------------
6. Syste Pumped
Name Vehicle License Number
Stewarts Sep lc 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
29,scr-n111F s dford ma
...........--------------
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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