HomeMy WebLinkAboutSeptic Pumping Slip - 1591 OSGOOD STREET 11/22/2017 RECEIVED
S-11\ C.Oryirrb`n'iruealth 'of* Massachusetts
City/Town' of North Andover V 1 201
System Pumping Record 'rOWN OF NOR'rii ANDOVER
F6rm 4 HEAL111 DEPAWMENT
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 ti
Ahe 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 tab J
key to move your Address
cursor-do not
use the return
key. Cityfrown State Zip Code
40----h
2. "ystern Owner:
��-�� Name
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping2. Quantity Pumped:
bate Gallons
3. Com' ponent� El Cesspool(s) [0, tic...
Tank El Tight Tank M,j"e se Trap
❑ Other(describe):
4. Effluent Tee Filter present? F1 Yes FI—N6" If yes, was it cleaned? F-1 Yes n No
5. Observed condition of component pumped:
S ste u ed
a9le Vehicle License Number
e " rt Septic 58 So Kimball St Bradford Ma
C mpan
7. Locati n e contents were disposed:
20s it bradford ma
• Sig e of uler Date
S�Oture of Receiving Facility(or attach facility receipt) Date
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