HomeMy WebLinkAboutSeptic Pumping Slip - 479 LACY STREET 8/15/2017 'C M' PIE
OM 'QMealth of Massachusetts
A 7
C'ty/Tow' n of North Andover
System Pumping Record
F6rm 4
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. System Location:
on the computer, I
use only the tab -ID Kh'
key to move your Address
cursor-do not I
use the return
key. City/Town State Zip Code
VQ 2. '3ystqm Owner:
Name
men
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping2. Quantity Pumped:
Date Wions
JA
3. Component: ❑ Cesspool(s) 71 Septic Tank F1 Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? n Yes No If yes, was it cleaned? ❑ Yes El No
5. Observed condition of componentpu ped:
6. System ape y:
Name Vehicle License Number
Stewar Septic 58 So Kimball St Bradford Ma
Compa y
7. Locati,n where contents were disposed:
20 so mill st bradford ma
Signature of Hauler Date
Signature of Receiving Facility(or attach facilityreceipt) Date
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