HomeMy WebLinkAboutSeptic Pumping Slip - 128 BRIDGES LANE 9/11/2017Commonwealth 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 pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms 1.
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
IMMO
System Location:
Address
c7s L
North Andover
City/Town
2. System Owner:
Far
Name
Address (if different from location)
City/Town
State
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
Date of Pumping
Date 2. Quantity Pumped:
3. Component: LI Cesspool(s)
0 Other (describe):
Septic Tank
4. Effluent Tee Filter present? 0 Yes 1;1—ifO
6.
5. Observed condition of component pumped:
6. System P....uoved By:
Name
/2U4frit,e.
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 t bradford ma
ature o auler
Signature of Receiving Facility (or attach facility receipt)
Gallons
El Tight Tank 0 Grease Trap
If yes, was it cleaned? El Yes ..Eg—NO
Vehicle License Number
Date
Date
/0)
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