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HomeMy WebLinkAboutSeptic Pumping Slip - 1895 SALEM STREET 5/24/2017 Commonwealth of Massachusetts � w r City/Town of North Andover a 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. System Location: on the computer, use only the tab key to move your Address —.... cursor-do not North Andover use the return _ key. City[Town State Zip Code 2. System weer: Name return I' Address(if different from location) CityfTown State Zip Code Telephone Number -........ B. Pumping Record 1. Date of Pumping ` "/—f-4 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) tic Tank © Tight Tank ❑ Grease Trap ❑ Other (describe): ... ......... --...-- 4. Effluent Tee Filter present? ❑ Yes 0-140— If yes, was it cleaned? ❑ Yes ❑ No 1 i 5. Observed condition of component pumped: 6. System Pumped By- Name Vehicle License Number' Stewarts Septic 58 So Kimball St Bradford Ma Company 7. Location where contents were disposed: 20 so mill st bradford ma Signature of Hauler -- Date Signature of Receiving acility(orattach_. ffacilik..... y y receipt) Date � t5form4.doc•11/12 System Pumping Record•Page 1 of 1