HomeMy WebLinkAboutSeptic Pumping Slip - 15 LONG PASTURE ROAD 12/12/2017 C 0
mM0111wealth of Massachusetts
CityTown of North Andover RECEIVED
ystem Pumping Record
F6rm 4
roWtq 0�'-'NORTH ANDOVER
DEP has provided this form for use by local Boards of Health, 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,
use only the tab . . /,5 n
key to move your Address
cursor-do not
use the return Cityrrown State Zip Code
key.
2 E' (stern Owner:
A/jo ro
Name',
matin
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. ComponeW El Cesspool(s) [""Septic Tank F] Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? F] Yes B-No If yes, was it cleaned? F1 Yes VT/No
5, Observed condition of compo ent pumped:
6. S rn ump
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 of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t6form4,doc-11/12 System Pumping Record-Page 1