HomeMy WebLinkAboutSeptic Pumping Slip - 566 FOREST STREET 5/8/2017Commonwealth 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 fa submitted to
the local Board of Health or other approving authority within 14 days from the pJJdate in
accordance with 310 CMR 15.351. 12'
A. Facility Information
Important: When
filling out forms 1. System Location:
use only the tab () Far:S± Sk- *
on the computer,
key to move your Address
cursor - do not o -ft(AiNf,r
use the return
key.
City/Town State
2. System Owner:
1,4,5\0.1 wa_
Address (if different from location)
City/Town
Zip Code
Stale Zip Code
Telephone Number
B. Pumping Record
tin
1. Date of Pumping
Date
2. Quantity Pumped:
3. Component: LI Cesspool(s) El Septic Tank 0 Tight Tank 0 Grease Trap
El Other (describe):
4. Effluent Tee Filter present? El Yes Er No If yes, was it cleaned? El Yes 111 No
5. Observed condition,of component pumped:
6. System Pump
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility (or attach facility receipt) Date
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