HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 10/12/2017Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Q her fqn rry used, but the
information must be substantially the same as that provided ht,r itsrform, check with your
At 04a
local Board of Health to determine the form they use. The SysteTh Pumping Rec6rd 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
Important: When
filling out forms 1. System Location:
on the computer, La5LAA/
use only the tab
key to move your Address
cursor - do not North Andover
use the return
key. City/Town
2. System Owner:
r
State Zip Code
4
Name
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
c•• 2. Quantity Pumped:
56o6
Gallons
3. Component: .-LI Cesspool(s) D Septic Tank 0 Tight Tank 0 Grease Trap
C)ILey
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes 0 No
5. Observed condition of component pumped:
If yes, was it cleaned? 1=1 Yes 0 No
6. System Pumped By:
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 Recelving Facility (or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1