HomeMy WebLinkAboutSeptic Pumping Slip - 464 FOSTER STREET 9/11/2017obrnrriOn'wealth 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 mustmustsubmitted to
-the local Board of Health or other approving authority within 14 days from the pumpin in
rO\accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms 1. System Location:
on the computer,
use only the tab l't it roAv 51 1 -
key to move your Address
cursor - do not
use the return
key. City/Town
2, Sjstem Owri
V01(0
Name
State Zip Code
N
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
Gallons
3. Component: [j Cesspool(s) jeptic Tank 0 Tight Tank Ej Grease Trap
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes E No If yes, was it cleaned? 0 Yes C1 No
5. Observed condition of component pumperd:
6. ystern Pumped
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
..,„
License Number
Signature of Hauler Date
Signature of Receiving Facility (or attach facility receipt) Date
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