HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 9/11/2017 (2)Important: When
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omrrioriwealth 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 us
information must be substantially the same as that provided here. Before us 0
local Board of Health to determine the form they use. The System Pumpi • d mus
The local Board of Health or other approving authority within 14 days from the p rripiTigl
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
ac;) titj‘
Address
City/Town State
2. System Owner:
but the
check with your
e submitted to
in
00\1°
i\11
S.PM"
Zip Code
Name
Address (if different from location)
City/Town State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
Cm
0000
Gallons
3. Component: 111 Cesspool(s) 1:1 Septic Tank [11 Tight Tank El Grease Trap
111 Other (describe): diudeie
4. Effluent Tee Filter present? 11 Yes fl No If yes, was it cleaned? Yes El No
5. Observed condition of component pumped:
Pumped By:
•
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Vehicle License Number
Signature of Hauler
Signature of Receiving Facility (or attach facility receipt)
Date
Date
t5form4.doc• 11/12
System Pumping Record • Page 1 of 1