HomeMy WebLinkAboutSeptic Pumping Slip - 60 SHERWOOD DRIVE 11/14/2017 a�M
RECEIVED
S. i..
Co'mrnonvuealth of Massachusetts
w City/Town of North Andover
I 1 i..V 1 /7 011
System Pumping Record TOWN OF NORTF1ANDOVE
HEALTH DEPARTMENT
Form 4.
yR DEP has provided this farm for use by local Boards of Health. Other farms may be used, but the
r,<4 information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the farm 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 Infbrmation
Important:When
filling out forms 1. System Loc tion:
on the computer, C
use only the tab
key to move your Address
cursor-do not North Andover _
use the return City/Town State Zip Code
key.
2. Sy �m Own r:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping" 2. 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 component pumped:
6. System Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bra ferd a
_ — 1
Signature of Mauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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