HomeMy WebLinkAboutSeptic Pumping Slip - 520 SHARPNERS POND ROAD 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. 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
Important: When
filling out forms 1. System Location'
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
t5form4.do
/12
6-00
Address
North Andover
City/Town
2. Systery Owner:
far'
Name
Address (if different from location)
61-0(4?—it7
ifyfVown
Slate
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
)
• Quantity Pumped:
Date Gallons
111 Cesspool(s) Septic Tank LJ Tight Tank Grease Trap
111 Other (describe):
4. Effluent Tee Filter present? 11 Yes
5. Observed condition of compone t pumped:
"60
19ff ((
6. Syste ped By:
r1
Name
Stewarts Septic 58 So Kimball St Bra
Company
7. Location where contents were disposed:
20 so ill st bradford ma
If yes, was it cleaned? LI Yes LI No
Vehicle License Number
Signatur of Hauler Date
Sign ure of Receiving Facility (or attach facility receipt) Date
System Pumping Record • Page 1 of 1