HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 10/12/2017 (3)Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key
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
1.
System Location:
A
C.--
.%) 1
ess
North Andover
City/Town
2. System Owner:
State Zip Code
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
q-14-11
1. Date of Pumping
Date
2. Quantity Pumped:
Gallons
3. Component: LI Cesspool(s) 0 Septic Tank 0 Tight Tank El Grease Trap
EK)ther (describe):
4. Effluent Tee Filter present? 11 Yes 0 No
5. �beved )ondi ion of componentpumped:
Orrir
If yes, was it cleaned? El Yes 111 No
6. yste Pumped By:
ame
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so m I st bradford ma
Vehicle License Number
Signs of Hauler
ignature of Receiving Facility (or attach facility receipt)
Date
Date
t5form4.doc• 11 1
System Pumping Record • Page 1 of 1