HomeMy WebLinkAboutSeptic Pumping Slip - 1935 SALEM STREET 7/12/2017Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
Commonwealth 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
1. System Location:
Address
North Andover
0(1
City/Town
2. System Owner:
C haPC) 1
Address (if different from location)
City/Town
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
El Other (describe):
z2. Quantity Pumped:
Gaions
Cesspool(s) Septic Tank 111 Tight Tank 11 Grease Trap
Date
4. Effluent Effluent Tee Filter present? LI Yes
5. Observed condition of com onent pumci p , :
ED
ystem um
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
If yes, was it cleaned? Lil Yes Lil No
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility (or attach facility receipt) Date
t5form4,doc• 11/12 System Pumping Record • Page 1 of 1