HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 11/16/2017 dl ' rAealth .of. Massachusetts RECEIVE
Idty/Town' of North Andover
$,ystern Pumping Record 100 OF'NOF�I'H ANDOVER f `
F6rm 4 HEN-Th DEpAJITMENT
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 submift(
the local Board of Health or other approving authority within 14 ays from the pumping date in
accordanoe with 310 CMR 15.351.
A. Facility Information
Important.Wheri
ffifing,out forint 1 System Location:
on the computer,
T
use only the tab 35
key to move your Address
cursor-, do not
usethereturn State Zip Code
key. W Cityfrown
� 2:"" Oystem ner:
Name',
Address(if different from location)
CWTown State Zip Code
Telephone Number
B. Pumping Re6ord
1— Date of Pumping Dat.e 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) n Septic Tank El Tight Tank f Grease Traj
❑ Other(describe):
4. Effluent Tee Filter present? El Yes El No If yes, was it cleaned? F] Yes El No
5. Observed condition of component pumped:
•
6. System Pumpe
Cl--BY- -
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date