HomeMy WebLinkAboutSeptic Pumping Slip - 210 RALEIGH TAVERN LANE 10/12/2017 Commonwealth of Massachusetts
City/Town of North Andover 100
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 Address
cursor-do not North Andover
use the return
key. CityfTown State Zip Code
2. System Owner:
Q
V
me
rsrrvn
N
Address(if different from location)
.. ......... --------
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping2. Quantity Pumped:
Date Gallons
��W,Z. 1
3. Component: El Cesspbol(s) kSeptic Tank El Tight Tank F1 Grease Trap
F Other(describe): .................
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? El Yes o
5. Observed condition of component pumped:
6. SystenyPT"p By:
Name VWO'e" U±,tum b er ----
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. L eaWn-wh re contents were disposed:
L
20 so mill stb dford ma
. ............... .................-Sig tur auler Date
Signature ofReceiving-Facility(or attach facility receipt) Date
t6form4.doc-11/12 System Pumping Record-Page 1 of 1