HomeMy WebLinkAboutSeptic Pumping Slip - 60 BEAVER BROOK ROAD 9/11/2017dbmrrfolivvealth 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 b ubmitted to
,the local Board of Health or other approving authority within 14 days from the pu
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forma 1. System Location:
use only the tab ;.)
on the computer,
key to move your Address
cursor - do not
use the return
key. City/Town
2. SI/stem Owner:
Name
((j
State Zip Code
Address (if different from location)
City/Town
Telephone.Number
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
Gallons
3. Component: .111 Cesspool(s) lit Septic Tank Lil Tight Tank D Grease Trap
LI Other (describe):
4. Effluent Tee Filter present? 11:1 Yes 0 No If yes, was it cleaned? LJ Yes 0 No
5. Observed condition of c m nent pumped:
6. System P
Name
Stewarts Septic 58 So Kimball St Bradford Ma(
Company
7. Location where contents were disposed:
Vehicle License Number
S nature Hauler
2raiiiikma
ett
Date
ignature of Receiving Facility (or attach facility receipt) Date
r
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