HomeMy WebLinkAboutSeptic Pumping Slip - 1220 SALEM STREET 9/11/2017Important: Wheri
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111t1.877
ComrriOnifflealth of Massachusetts
City/Town of North Andover
System Pumping Record
Fcirm 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 pumpin
accordance with 310 CMR 15.351. - in
A. Facility Information
1. System Location:
Address
2. stemOwner
Name
7 i) 2— Addre sirdifferent fr m loc
Ci
B. Pumping Record
1. Date of Pumping
3. Component: LJ Cesspool(s)
121 Other (describe):
4. Effluent Tee Filter present? LI Yes
State
Zip Code
Telephone Number
2. Quantity Pumped:
ptic Tank Tight Tank E1 Grease Trap
5. Observed condition of comp ent pu ed:
If yes, was it cleaned? El Yes
6. Sys 14-4-umped 8y:
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Locatio ere ontents were disposed:
20 so 111 st braqford
Vehicle License Number
Signature of Receiving Facility (or attach facility receipt) Date
t5form4.doc. 11/12
System Pumping Record. Page 1 of 1