HomeMy WebLinkAboutSeptic Pumping Slip - 107 ROCKY BROOK ROAD 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
local Board of Health to determine the form they use. The System Pumping Record must b
the local Board of Health or other approving authority within 14 days from the pumpin
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms 1.
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key
System Location:
(S-1-(--)
Address
North Andover
City/Town
2. System Owner:
r ka-K
Name
Oltate
Address (if different from location)
City/Town
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1
Date of Pumping
3. Component:
Date
2. Quantity Pumped:
111 Cesspool(s) Septic Tank 11] Tight Tank
El Other (describe):
4. Effluent Tee Filter present? El YesKJo
5. Observed condition of component pumped:
C-e535
6. System Pumped By:
Gallons
1:1 Grease Trap
If yes, was it cleaned? 111 Yes 111 No
N meCt-
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Vehicle i e Number
7
S nature Hauler
Signature of ReceivingFacility (or attach facility receipt)
8---Cf-L2
Date
Date
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