HomeMy WebLinkAboutSeptic Pumping Slip - 115 LACONIA CIRCLE 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
V D
JUL `Z 701
WA OF NORTH ANDOvER
HEALTH DEPARTMENT
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:
LL'(LC
Address
\,i(vicA
City/Town
2. System Qwner:
Name
State
Address (if different from location)
City/Town
State
Zip Code
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
1.q
Date
3. Component: 111 Cesspool(s)
[11 Other (describe):
uantity Pumped:
Gallons
Septic Tank El Tight Tank El Grease Trap
4. Effluent Tee Filter present? 111 Yes No If yes, was it cleaned? LI Yes El No
5. Observed condition of component pumped:
6. Systp.na..P"umped By:
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents we disposed:
t bradford
Sig1c1 of
„.-
Vehicle License Number
Date
Signature of Receiving Facility (or attach facility receipt)
Date
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1