HomeMy WebLinkAboutSeptic Pumping Slip - 4 EVERGREEN DRIVE 9/11/2017Commonwealth of Massachusetts
City/Town of North Andover
ystem 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 submid to
the local Board of Health or other approving authority within 14 days from the pumping da
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms 1. System Location:
use only the tab
on the computer, key to move your Address
LLE
,,frEf-cfn Dr,
cursor - do not
use the return
key.
North Andover
City/Town
2, Syst m Owner:
r
Name
Address (if different from location)
City/Town
State
State
Telephone Number
Zip Code
Zip Code
rq < (9
B. Pumping Record
2-,(511
1. Date of Pumping . Quantity Pumped:
Date Gallons
C (7) 0
3. Component: Lil Cesspool(s) J Septic Tank 0 Tight Tank LI Grease Trap
0 Other (describe):
4, Effluent Tee Filter present? 0 Yes n No
5. Observed condition of component p ped:
7-05D
If yes, was it cleaned? 0 Yes El No
6. Syste -fiumped-By)
)
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed
20 so mill st br dfo d ma
Sig ature of Hauler
gnature of Receiving Facility (or attach facility receipt)
Date
Date
15form4.doc• 11/12
System Pumping Record • Page 1 of 1