HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 7/12/2017 (4)Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
C V
JUL. ?..'2011
TOWN OF NORTH A.NDOVER
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:
f AJ
Address
City/Town
2. System wner:
C
Name
State Zip Code
Address (if different ro location)
City/1-own
State Zip Code
Telephone Number
B. Pumping ReCord -2S:27
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: LI Cesspool(s) 11 Septic Tank 0 Tight Tank 0 Grease Trap
LI Other (describe):
4. Effluent Tee Filter present? LI Yes LI No If yes, was it cleaned? 0 Yes 0 No
5. Observed condition of component pumR
<:1)1( '4""
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
r.
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility (or attach faciHty receipt) Date
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