HomeMy WebLinkAboutSeptic Pumping Slip - 793 FOREST STREET 10/12/2017 Commonwealth m� ���Massachusetts
���� usetts
City/Town of North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other be used, butthe
information must be substantially the nomo on that provided hone. Before using this form, check with your
local Board nfHealth bodetermine the form they use. The System Pumping Record must besubmitted ho
the local Board ofHealth orother approving authority within 14days from the pumping date in
accordance with 31OCN1R15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
onthe computer,
use only the tab
key to move your Ad400mu
cursor-do not
North Andover
use the return
key. City/Town State Zip Code
2. System Owner:
VQ
Name
'
Address(if different from|oomUvn)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1 C)ntn of Pumping -- 2 Quantity Pumped: -----������-----��
� oo�r � � Gallons
3. Component: Fl Cesspool(s) Septic Tank El Tight Tank Fl Grease Trap
[] Other(describe): ------
4. Effluent Tee Filter present? El Yes 0 No If yes, was it cleaned? 0 Yes F� No
S. Observed condition of component pumped:
6. System Pum d-By'
Vehicle License Number
Name
Stewarts Sep ic 5i�'So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill stbradford ma
sig nemmofHau|m Date
9i0nomoo�nooaiv|noFeoUity(oraiianohmmtyreceipt) Date