HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 7/12/2017 (2)Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
•C V
1 2- 7°1/
/00 OF NORTH ANDOVER
HEALTH DEPARTUENT
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:
kul I le
Address
City/Town
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
3. Component:
El Other (describe):
Date
i72. Quantity Pumped:
LJ Cesspool(s) Septic Tank LI Ti ht Tank
( oak
4. Effluent Tee Filter present? Yes II No
5. Observed condition of component pumped:
6. System Pumped'By:
Name
Stews S
Com&ny'
Gallons
11 Grease Trap
If yes, was it cleaned? III Yes 111 No
58 So Kimball St Bradford M
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
Date
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