HomeMy WebLinkAboutSeptic Pumping Slip - 910 JOHNSON STREET 12/12/2017 RECLEIVED
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City/To W* n of North Andover
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em Pumping Record 'C
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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 yj
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,
use only the tab 6ha--sw
key to move your Address
cursor-do not
use the return City/?own State Zip Code
key.
2 Oystem Owner: 44
Name',
Address(K different from location)
cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping2. Quantity Pumped:
Date Gallons
3. Co.rnponent� ❑ Cesspool(s) Septic Tank El Tight Tank n Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
LZ
6. System Pumped By:
t
Name Vehicle License Number
Stewarts Septic 58 So Kimbell 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
t6form4.doc-11/12 System Pumping Record-Page 1