HomeMy WebLinkAboutSeptic Pumping Slip - 2198 TURNPIKE 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 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:
use only the tab atC( g' Tik1/47-n1a
on the computer, -C>-
key to move your Address
cursor - do not
use the return
key
North Andover
City/Town
2. System Owner:
ct,n()
Name
Address (if different from location)
City/Town
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
3. Component: LI Cesspool(s)
111 Other (describe):
4. Effluent Tee Filter present? 11 Yes Lil No
5. Observed condition of component pumped:
6. System Pumped By:
Na
arts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
2. Quantity Pumped:
wc
Gallons
a/Septic Tank Li Tight Tank El Grease Trap
If yes, was it cleaned? D Yes LI No
Vehicle License Number
ture of Hauler
inature of Receiving Facility (or attach facility receipt)
LL
Date
Date
t5form4,doc• 11/12
System Pumping Record • Page 1 of 1