HomeMy WebLinkAboutSeptic Pumping Slip - 1535 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 p ping date in
accordance with 310 CMR 15.351,
A. Facility Information
Important: When
filling out forms 1.
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key
System Location:
Address
North Andover
City/Town
2. System Owner:
\CD.VA0-)t<C1(
Name
Address (if different from location)
City/Town
State
Zip Code
State Zi
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
El Cesspool(s)
0 Other (describe):
4. Effluent Tee Filter present? 11] Yes 0 No
5. Observed condition of component pumped:
---, - Da . Quantity Pumped:
127,2
te
6. Syste mped By:
Na
Stewarts Septic 58 So Kimball St
Gallons
Septic Tank 0 Tight Tank Lil Grease Trap
adford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford m
Sign ure of Hauler
nature of Receiving Facility (or attach facility receipt)
If yes, was it cleaned? 0 Yes LI No
Vehicle License Number
Date
Date
J
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