HomeMy WebLinkAboutSeptic Pumping Slip - 112 TUCKER FARM ROAD 11/16/2017 Pjq�ma'n�wealth of Massachusetts
RECEIVED
City/Tow' n' of North Andover
,ystem Pumping Record
F6rm 4 T OF I40,Tj�j/SNDOVER
J�IEA'JlrLjDARTMENT
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 yoL
local Board of Health to determine the form they use. The System Pumping Record must be submitted t
-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
on the computer'
use only the tab1/0i �C_I�LQ
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2.* 8�stem Ovyner:
Name
reaan
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping /7 2. Quantity Pumped:
Date Gallons
3. Component.-, ❑ Cesspool(s) ZSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? El Yes EW 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 bradf6rd ma
Signature auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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