HomeMy WebLinkAboutSeptic Pumping Slip - 41 BRUIN HILL ROAD 10/12/2017Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
City/Town pf North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms e 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
1.
System Location:
\ ',AA n tt
Address
North Andover
City/Town State Zip Code
2, System Owner: •
O NiNo, (NI
Address (if different from location)
City/Town
State Zip Code
CO`
Telephone Number
B. Pumping Record
1. Date of Pumping
Date 11
2. Quantity Pumped:
I 5' crZ
Gallons
3. Component: Cesspool(s) Septic Tank 0 Tight Tank 0 Grease Trap
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? 0 Yes El No
5. Observed condition of component pumped:
-0_
6. SynfPumped By.
FaM/k/6
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford m
Signatu e of Hauler
ure of Receiving Facility (or attach facility receipt)
VehicleVehcte License Number
Date
Date
t5form4.doc• 11/12
System Pumping Record • Page 1 of 1