HomeMy WebLinkAboutSeptic Pumping Slip - 216 FOSTER STREET 7/12/2017Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
7
vovsk
EtA-f
:4'004,0' •
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
System Location:
Ot
Adaress
c\ CNI
City/Tow
2. System Owner:
?)a
State Zip Code
Name
Address (if different from location)
City/Town
State Zip Code
CP 0 ),
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component: L Cesspool(s)
Li Other (describe):
4. Effluent Tee Filter present? El Yes El No
5, Observed condition of componr pumped:
Date ( ry.../...„.„2) 2. uantity Pumped:
/0-0
Gallons
Septic Tank El Tight Tank El Grease Trap
If yes, was it cleaned? LI Yes 111 No
6. Tr7
Syste umped By: r---
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 s. mill st bradfo
Sign ure of H uler
nature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
Date
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