HomeMy WebLinkAboutSeptic Pumping Slip - 170 OLYMPIC LANE 10/12/2017 i
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record ���.° �
Form 4 ` �, g� � .,i�.
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 Locatioh:
on the computer, � ,� 2,
use only the tab _.___-. - C.J __, _� 1 ./. ...
key to move your Address
cursor-do not North Andover �_
use the return _...... ........
key. City/Town State Zip Code
2. System Owner:
rah
'Name---
Address
ameAddress(if different from location)
CityfFown State Zip Code
Telephone Number
— — - ..............____..... —
B. Pumping Record
� M
1. Date of Pumping -- Quantity Pumped: �� .....
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): __ _ .... . . .
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compone t pumped:
......
... ....... _.--.....
B. Systrf 15umped By: c" ❑ ,
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 s mill st br f a
Signat r of au er Date
_._ --
Sig ure of Receiving Facility(or attach facility receipt) Date
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