HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 10/12/2017 (2)Commonwealth of Massachusetts
City/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.
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
System Location:
Address
North Andover
City/Town
2. System Owner:
) Name
Address (if different from location)
City/Town
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1.
Date of Pumping
3. Component:
El Other (describe):
4. Effluent Tee Filter present? El Yes El No
5. Observed condition of component pumped:
6. System Pu
Name
Stewarts Septic 58
Company
7. Location where contents were disposed:
Kimball St Bradford Ma
20 so mill st bradford ma
Signature of Hauler
Signature of Receiving Facility (or attach facility receipt)
2. Quantity Pumped:
GPZeCt-7
111 Cesspool(s) 0 Septic Tank 111,,,Tic,ht Tank 0 Grease Trap
l(qP 40114
If yes, was it cleaned? El Yes 0 No
('3 (12
Vehicle License Number
Date
Date
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