HomeMy WebLinkAboutSeptic Pumping Slip - 1591 OSGOOD STREET 5/30/2017 Commonwealth of Massachus6tts
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 to in
accordance with 310 CMR 15,351.
A. Facility Information
Important:When R 5%
filling Out forms 1. System Location:
on the computer, ell
use only the tab N, ---------- -—----
key to move your Address
cursor-do not
use the return -I -h,"
key. CityfTown state Zip Code
2, System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
—------------------
B. Pumping Record
1000
1. Date of Pumping -Date 2. Quantity Pumped: Gallons --- --------
3. Component: El Cesspool(s) n Septic Tank P Tight Tank [Grease Trap
El Other(describe): ---------------
4.
--------
4. Effluent Tee Filter present? El Yes El No If yes, was it cleaned? F] Yes F1 No
5. Observed condition of component pumped:
-- --------------- - ------
.............
6. System Pumped By:
.......... .. ....... .. ..........................
Name
Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Sig lure uler Date
--------------------
Signature of Receiving Facility(or attach facility receipt) Date
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