HomeMy WebLinkAboutSeptic Pumping Slip - 122 OLYMPIC 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. System Locati n: ,
use only the tab WA 0 WC(\ PV c .
on the computer, Ln
key to move your Address
cursor - do not
use the return
key.
North Andover
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
arci
State
A A
Do4E5'
E.\z
Zip Code
9g- (6 Code
/P
State
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component: Lil Cesspool(s)
111 Other (describe):
4. Effluent Tee Filter present? 111 Yes
Date
5. Observed condition of componentipumped:
6. System Pumped
Name
Stewarts Septic 58 So Kimball St Bradfo
Company
7. Location where contents were disposed:
2 so mill st br. ma
Sigi ature of Hauler,
uantity Pumped:
Gallons
Septic Tank El Tight Tank LI Grease Trap
If yes, was it cleaned? 111 Yes 11 No
Vehicle License Number
Date
Si ture of Receiving Facility (or attach facility receipt) Date
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