HomeMy WebLinkAboutSeptic Pumping Slip - 951 FOREST STREET 5/10/2017Important: When
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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 pu ing date in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
qs-1 Ad ress
ress
OndO\iff
City/Town
2. System
Name
wner:
(5„on
1
State Zip Code
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
3. Component: 111 Cesspool(s)
II Other (describe):
4. Effluent Tee Filter present? El Yes El No
soo
2. Quantity Pumped:
Gallons
Er/Septic Tank 111 Tight Tank El Grease Trap
5. Observed
ame
ndition of component pumped:
m Pumped By:
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
nature of Hauler
Signature of Receiving Facility (or attach facility receipt)
If yes, was it cleaned? 111 Yes Lil No
Vehicle License Number
Date
Date
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