HomeMy WebLinkAboutSeptic Pumping Slip - 535 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 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. C WE
A. Facility Information
Important: When
filling out forms 1. System Location:
use only the tab :5 Vid-C,
on the computerY
,
key to move your Address
cursor - do not North Andover
use the return
City/Town
key
2, System Owner:
Name
Address (if different from location)
City/Town
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
k-,-Y
Date
2. Quantity Pumped:
Gallons
3. Component: El Cesspool(s) Septic Tank El Tight Tank 0 Grease Trap
0 Other (describe):
4. Effluent Tee Filter present? E] Yes 0 No If yes, was it cleaned? 0 Yes No
5. Observed condition of component pumped:
6. Sysiem..Eumped By:
Name -
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility (or attach facility r
ipt)
Date
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