HomeMy WebLinkAboutSeptic Pumping Slip - 280 GRANVILLE LANE 10/12/2017 Commonwealth of Massachusetts w
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City/Town of North Andover
System Pumping Record
Farm 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: t
on the computer,
use only he tab �°' L� ...
key to move your Address
cursor-do not North Andover
use the return --.___.__. _..__.
key. Citylrown State Zip Code
2. System Owner:
reg
�� 1"02 / C _❑_._........
Name
raarn
Address(if different from location)
._..._ ._...... .
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping � 22 c� �� / sC
___ 2. Quantity Pumped: .__
Dato Lallans
& 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 component pumped:
6. System Pumped Bye"
Name Vehicle License Number
Stewarts Septic 58 Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
S6gnature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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