HomeMy WebLinkAboutSeptic Pumping Slip - 47 BOXFORD 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 m t be submitted to
the local Board of Health or other approving authority within 14 days from the ate in
accordance with 310 CMR 15.351.•
A. Facility Information
Important: W hen
filling out forms 1. System Locatio
on the computer,
use only the tab 4-1 rt 1/:f
key to move your Address
cursor - do not North Andover
use the return
key. City/Town
too
IMO
2. System Owner:
Sqt VV
Li
State Zip Code
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Component:
Lil Cesspool(s)
Lil Other (describe):
4. Effluent Tee Filter present? 111 Yes ID No
5. Observed condition of component p ped:
6. Sys-PtImped
S-7/7(j qc
Name
Stewarts Septic 58 So Kimball St\Br_a ford Ma
Company
State
Zio Co
Telephone Number
uantity Pumped:
Septic Tank Lil Tight Tank
7. Location where contents were disposed:
20 mill st bradfordjn
Okr\--12_—•
Signa ure of Hauler
52- o
Gallons
II] Grease Trap
If yes, was it cleaned? Eli Yes El No
5
Vehicle License Number
Date
ignature of Receiving Facility (or attach facility receipt) Date
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