HomeMy WebLinkAboutSeptic Pumping Slip - 743 JOHNSON 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 Locatio
on the computer, ---
use only the tab
key to move your Address
cursor - do not North Andover
use the return
City/Town
key.
2. System Owner:
1
Name
Address (if differentfrom lo ion)
City/Town
State Zip Code
State Zip Code
Telephone Nurnber
B. Pumping Record
1. Date of Pumping 1 2. Quantity Pumped:
Date Gallons
3. Component: Lil Cesspool(s) 111—'54tic Tank EI Tight Tank Grease Trap
D Other (describe):
4. Effluent Tee Filter present? 111 Yes Et1io If yes, was it cleaned? D Yes EI No
5. Observed condition of component pumped:
6. System Pumped By:
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler
Signature of Recej. (or attach facility receipt)
Vehicle License Number
Date
Date
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