HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 9/11/2017Important: When
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ComrriOn'wealth 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 pumpin
accordance with 310 CMR 15.351.
A. Facility Information
1.
System Location:
3(--;-1 101\00 kfl
Add \V\C0\Jt(
City/Town
2. g'stem Owner:
660;(-7
Name
State Zip Code
" 4
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
Other (describe):
Date
2. Quantity Pumped:
Cesspool(s) 0 Septic Tank
Gallons
0 Tight Tank 0 Grease Trap
4. Effluent Tee Filter present? 0 Yes El No If yes, was it cleaned? 0 Yes 0 No
5. Observed ondition of component pumped:
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Locatinn-where contents were disposed:
0 mill st bradford ma
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
t5form4.doc• 11/12
System Pumping Record • Page 1 of 1