HomeMy WebLinkAboutSeptic Pumping Slip - 2189 SALEM STREET 8/15/2017Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health, Other for ay 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 System Location:
on the computer, (
use only the tab () ( g 1 • Sri itl‘
key to move your
cursor - do not Addre(N. ) d U \ft
use the return
key City/Town
2. System Owner: '
State Zip Code
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
Gallons
3. Component: L Cesspool(s) Septic Tank Tight Tank 0 Grease Trap
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes 0 No If yes, was it cleaned? 0 Yes LI No
5. Observed gondition of component pumped:
Ve)C.4
ystem Pumped By:
e
Stewarts Septic 58 So Kimball St Bradford Ma
Company
Location where contents were disposed:
2
s
radford ma
Vehicle License Number
Date
Signe titre of Receiving Facility (or attach facility receipt) Date
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