HomeMy WebLinkAboutSeptic Pumping Slip - 404 SALEM STREET 7/12/2017Commonwealth 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 Rec st be submitted to
the local Board of Health or other approving authority within 14 days fr, date in
accordance with 310 CMR 15.351.
(2_ ?V
A. Facility Information
Important: When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key
tab
RIO
„Saliorn
Address
North Andover
City/Town
2, System Owner:
//
Name
Address (if different from location)
City/Town
State
Zip Code
State . Zip Code
Telephone Number
B. Pumping Record
1. Date Date of Pumping uantity Pumped:
Date
3. Component: [1] Cesspool(s) LYSeptic Tank [11 Tight Tank 111 Grease Trap
El Other (describe):
4. Effluent Tee Filter present? 111 Yes
5. Observed condition of componcet pumped:
Gallons
If yes, was it cleaned? 111 Yes El No
6. Syste -PGmped
/lief Lcef '77
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Br f d Ma
Company
7. Location where contents were disposed:
2 so mill st bradford ma
Si nature of Hauler
Date
ignature of Receiving Facility (or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1