HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 10/5/2017 RECEIVED
10-6irr?, ivlirealth of Massachusetts
City/Town of North Andover NOV I "I
!�ystem Pumping Record
TOWN OF NORTHANDOVER
F6rm 4 I-EALDI DEPAUMENT
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
local Board of Health to determine the form they use.The System Pumping Record must be submittE
-the local Board of Health or other approving authority within 14 ays from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important-Whe6
f0fing out form§ 1 System Location:
on the computer,
use only the tab
key to move your Address
cursor-
, do not
use the-return a. Cftyfrown state 4 Zip Code
key. Qk
&0--h 2.* System Owner:
2 CI ',AX)
Address(If different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Re6ord
1— Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Co I mponentw El Cesspool(s) R Septic Tank ❑ Tight Tank Q Grease Trai
El Other(describe):
4. Effluent Tee Filter present? R Yes El No If yes, was it cleaned? [:1 Yes El No
5. Observed condition of component pumped:
6. System Pumped,By--"�""�
Namew.,.
Vehicle License Number
Stewarts Septio-59-8—coKimball b"all St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradf6rd ma
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
19197