HomeMy WebLinkAboutSeptic Pumping Slip - 26 LONG PASTURE ROAD 5/24/2017 Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Farm 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 purr i date in j
accordance with 310 CMR 15.351.
.4. Facility Information � �,� �
Important:when � �,��Ltt"����
filling out forms 1. System Location: V)04 t1 tCtV�'�C w tt
on the computer, /�� 7 p Vc a �0OJA
use only the tab -..... _ 11l t 1,....
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key to move your Address �
cursor-do not North Andover
use the return --------.
key. City/Town State Zip Code
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2. System Own r:
Name --
mnerr
Address(if different from location)
City/Town State - Zip Code -
Telephone Number
----- - ---------------- ----------------- -----
B. Pumping record
1. Date of Pumping -- Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ ,Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes [] No
5. Observed condition of component pumped:
6. Systtxt Pumped Byr
J,
........... ---
Name Vehicle License Number
Stewarts Septic 58 So Kimball St radford Ma
Company
7. Location where contents were disposed:
J
0 so mill st bra_dforo ma
S ture of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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