HomeMy WebLinkAboutSeptic Pumping Slip - 75 TANGLEWOOD LANE 9/11/2017oOrnnionVvealth 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 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 pumpi date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When .
filling out forms 1. System Location:
use only the tab --1 S -van \c-u, a 1,,,n
on the computer,
cursor - do not Adss ti\ \ c
C
key to move your
use the return
key City/Town
2. S'stem Owrier:
Namevo I p) 0
State
Zip Code
Address (if different from location)
City/Town
State Zip Code
Tetephor le Number
B. Pumping Record
n r,{1;
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: El Cesspool(s) Septic Tank 111 Tight Tank Grease Trap
El Other (describe):
4. Effluent Tee Filter present? El Yes( No If yes, was it cleaned? fl Yes
5. Observed condition of component pumped:
6. Sys Pumped By
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill stbrad rd ma
Ure of Hauler
Vehicle License Number
Signature of Receiving Facility (or attach facility receipt) Date
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