HomeMy WebLinkAboutSeptic Pumping Slip - 453 FOREST STREET 12/12/2017 RECEIVED
-<C—\ cbrn,m`o`nwealth* of Massachusetts
CftWTown of North Andover
$
i�ovl OF tKJR�flI MMOVER ystem Pumping Record 1.�EAJ�I[MTARI NIE14T
F6rm 4
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 16.351.
A. Facility Information
Important:When
filling out forms . 1. System Location:
on the computer,
3
use only the tab
key to move your Address
cursor-do not
use the return
key. Cityfrown State Zip Code
4"--h 2h 4 4 4 �
IOD2�A 2.� gWem Owner:
Name
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping oat f 2, Quantity Pumped: -6-allons
3. Cornponent:' n Cesspool(s) ageptic Tank n Tight Tank El Grease Trap
0 Other(describe):
4. Effluent Tee Filter present? M Yes No If yes, was it cleaned? F] Yes ffNo
5. Observed condition of co onentpumped:
6. Syst umped
Ry
C
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
t5form4.doc-11/12 System Pumping Record-Page 1