HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 5/19/2017Commonwealth 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. „kflm
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0601001
A. Facility Information
Important: When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor - do not
use the return
key.
35/ Wiiiot
North Andover
CityfTown
2. System er:
Name
Le_
Address (if different from location)
City/Town
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
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1. Date of Pumping / 7 2. Quantity Pumped:
Date Gallons
3. Component: LI Cesspool(s) 0 Septic Tank 0 Tight Tank El Grease Trap
111 Other (describe):
4. Effluent Tee Filter present? 0 Yes 0 No If yes, was it cleaned? El Yes 0 No
5. Observed condition of component pumped:
6. System Pumped By:
Name
Stewarts Septic 58 So
Company
Vehicle License Number
-StBradford Ma
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler Date
Signature of Receiving Facility (or attach facility receipt) Date
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