HomeMy WebLinkAboutSeptic Pumping Slip - 57 CHRISTIAN WAY 11/16/2017 lcbr �1a'nwealth of Massachusetts RECEIVED
City/Tow' n* of North Andover
$,yster Pumping Record TOWN U�:11ORTH AMMER
F6rm 4 H 0EPARMENT
ilEALT
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 y(
local Board of Health to determine the form they use. The System Pumping Record must be submitted
-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, C'11*1,/*'/,-
use only the tab 5 3 7
7 a'�_11W�
key to move your Address I I
cursor-do not /AV,), 4,d
use the return
key. Cityfrown State Zip Code
2 *stem Owner:
k�
mun
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1 Date of Pumping Date 2, Quantity Pumped: Gallo6s'
3. Component:' Ej Cesspool(s) MSeptic Tank [I Tight Tank F1 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? El Yes [71No If yes, was it cleaned? 0 Yes El No
5. Observed condition of component pumped:
6. System Pumped By:
Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were'disposed:
1
"mill brad rd M
IC
Signattk Date
Signature of Receiving Facility(or attach facility receipt) bate
t5form4.doc-11/12 System Pumping Record-Page 1