HomeMy WebLinkAboutSeptic Pumping Slip - 273 REA STREET 9/11/2017 Commonwealth of Massachusetts
City/Town of North Andover
1,3 2
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 I D
accordance with 310 CMR 15.351.
A
A. Facility Information
os
Important:When
filling out forms 1. System Location-
V
on the computer, �AVV
use only the tab ...... .......
key to move your Address
cursor-do riot North Andover
use the return ....................
key. CityfTown State Zip Code
2. System Owner::
Name
mien
......................
Address(if different from location)
.............. ------- ----—-------------........................
City[Town State Zip Code
Telephone I Number
B. Pumping Record
1. Date of Pumping
2. Quantity Pumped:
Date 4,ons-'
3, Component: R Cesspool(s) dSeptic Tank El Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? El Yes El No
5. Observed conditionff component pumped:
I.................. ......-------- ......... ................
6. System-P51m�, pRed,,.B
4,1
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
—--------------
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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