HomeMy WebLinkAboutSeptic Pumping Slip - 71 PADDOCK LANE 5/11/2017Commonwealth 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 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.
A. Facility Information
Important: When
filling out forms 1.
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key
System Location:
hC\idal(-.
Address
North Andover
City/Town
2. System Owner:
Name
State
Address (if different from location)
City/Town
\00\15
'r\
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
11-11
Date
1. Date of Pumping
3. Component:
2. Quantity Pumped:
Gallons
LI Cesspool(s) 0, Septic Tank LI Tight Tank Lil Grease Trap
LI Other (describe):
4. Effluent Tee Filter present? 111 Yes No
5. Observed condition of component pumped: )
LA-7
6. System Pumped By
Stewarts Septic 58 So Kimball S
Company
If yes, was it cleaned? Lil Yes No
Bradford Ma
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
Date
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