HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 8/15/2017 (3)Important: When
filling out forms
onthe computer,
use only the tab
key tomove yov,
cursor -uonot
use the return
key
'
100
Commonwealth of Massachusetts
��{��l����[ll8/����/u/ ��/
��'fx/T f North Andover
`�| C�VVD C]/ � � [�V8�[
��' / /v /v/ r� w
System Pumping
Record
������00 n ����U��
� � ��
Form 4
OEP 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 Uodetermine the form they use. The System Pumping Record must be submitted to
the local Board ofHealth orother approving authority within 14days from the pumping date in
accordance with 310CIWR15.351.
A. Facility Information
1. System Location:
W-1 \ hbal a-V 7C
)
Address
North Andover
2. System Owner:
Name
/k
U\,
Address (if diff erent from location)
State Zip Code
Telephone Number
B. Pumping Record
1. Date ofPumpimg
v [x/�mUvPnmnod'
Date
— ----� Pumped:
3. Component: El Cesspool(s) El Septic Tank
�� Other (describe):
4. Effluent Tee Filter present? 0 Yes El No
5. Observed ondition of component pumped:
__
8. podBy:
�
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 o~fnd-'�-bnadford ma
Sign IX.&-rmRuuxx
El Tight Tank
Gallons
[9-'Grease Trap
If yes, was it cleaned? El Yes El No
Vehicle License Number
Signature of Receiving Facility (or attach facility receipt) Date
mfonn4.uoo^11/12 System Pumping Record ` Page 1m1