HomeMy WebLinkAboutSeptic Pumping Slip - 248 BRIDGES LANE 7/12/2017Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
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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.
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
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System Location:
ridcS LT)
Address
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1.
Date of Pumping
State
Telephone Number
Date 1'1
3. Component: LI Cesspool(s)
0 Other (describe):
4. Effluent Tee Filter present?
uantity Pumped:
/ Sea
Gallons
Septic Tank 0 Tight Tank 111 Grease Trap
Yes 0 No If yes, was it cleaned? - Yes 0 No
5, Observed condition of component pumped:
6. Sytem-Fri:mped By:
V71,er
Name
Stewarts Septic 58 So Kimball St B
Company
7. Location where conte
0 so mill st bradf
tA.A
ignature of Hauler
dford Ma
s were disposed:
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
Date
11/12 System Pumping Record • Page 1 of 1