HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 9/11/2017 (3)Important: W hen
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Commonwealth 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
1. Sysiem Location:
Address
North Andover
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component: Lil Cesspool(s) [I] Septic Tank
0-'6ther (describe):
Date
4. Effluent Tee Filter present? El Yes 111 No
5. Observed ondition of component pumped:
ped By:
e
warts Septic 58 So Kimball St Bradford Ma
Company
7. Location w ere contents were disposed:
20.iIIst bradford ma
Signature of Ha
2. Quantity Pumped:
0 Tight Tank 111 Grease Trap
If yes, was it cleaned? LJ Yes 0 No
Vehicle License Number
Date
ature of Receiving Facility (or attach facility receipt) Date
t5form4.doc• 11/12
System Pumping Record • Page 1 of 1