HomeMy WebLinkAboutSeptic Pumping Slip - 54 LONG PASTURE ROAD 7/12/2017Commonwealth nfMassachusetts
�^�]�q�l[][]\0����/u / ��/
��'fw/T f North Andover
��|^�/ ^ ��VV�� ��/ / a[]/ �/ . r���`�C]\/e[
���s���� ������.��� ���������
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 deb* in
accordance with 310CK4R15.351.
A Facility Information
| When
filling out forms
onthe computer,
use only the tab
key wmove your
oumv, do not
use the return
key
"810
/
System Location:
6-�-j Lbkc��
Address
North Andover
City/Town
2. System Owner:
L<+�'\
� Narne
Address (if different from location)
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping
v r)mmav Pxmnp��
oom^� --~''~, ' ~'"r~~�
3. Component: Cesspool(s) M/Septic Tank
El Other (describe):
���
4. E�uentTee Fi|bnpresent? El Yes �Y No
5. Observed condition of componentpumped:
6� System Pumped By:
Name
StewartoSeptic 988oKimball St Bradford Ma
Company
7. Location where contents were disposed:
20sonAl utbrafnrd ma '
Si
nature of Ka6ler
Signature of Receiving Facility (or attach facility receipt)
[l Tight Tank El Grease Trap
If yes, was it cleaned? 0 Yes El No
Vehicle License Number
�11
t5form4.doc- 11112 System Pumping Record - Page 1 of 1