HomeMy WebLinkAboutSeptic Pumping Slip - 110 FOREST STREET 5/19/2017 Commo,nwealth 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 d in
accordance with 310 CMR 15.351.
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A. Facility Information
Important:When
filling out fortab'
s 1. System Location,
on the compt
use only the —h-0 -"rl
---------- ...........
key to move your Address
cursor-do not North Andover
use the return
key. CityfTown State Zip Code
2. System) Owner:
ran
A IS C-6 k ................................
x
Name
reuan
Address(if different from location)
... .............._....—
Cityff own
...........
State Zip Code
........................... .....
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: El Cesspool(s) Septic Tank El Tight Tank El Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? F] Yes /N o If yes, was it cleaned? n Yes F] No
5. Observed condition of component pumped:
Ro'
—------ ---------------------
6, S e Pe I)E'
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
orn p a n y
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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