HomeMy WebLinkAboutSeptic Pumping Slip - 139 OLYMPIC LANE 10/12/2017 Commonwealth of Massachusetts
Cit /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 Locati
on the computer,
use only the tab ......
key to move your Address
cursor-do not North Andover
use the return --------...........
key. City[Town State Zip Code
2. System Owner:
Name
renxa
Address(if different from location)
CityCl own State Zip Code
Telephone N-umbert
B. Pumping Record
---------------
1. Date of Pumping , Quantity Pumped:
Date Gallons
3. Component: F1 Cesspool(s) Septic Tank El Tight Tank n Grease Trap
R Other(describe): ............ - ------------------
4.
--4. Effluent Tee Filter present? F-1 Yes [f No If yes, was it cleaned? El Yes El No
5. Observed condition of component pumped:
............
6. Systpj)i-Pumped By,---
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
-Company
-
7. Location where contents were disposed:
20 o mill st bradfRo:.
01 "D
Sig ature of Hauler Date
❑ — .. ................
of
ignatu6r�e of Receiving Facility(or attach facility receipt) Date
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