HomeMy WebLinkAboutSeptic Pumping Slip - 21 CHERISE CIRCLE 12/12/2017 Cam.mprnwealth of Massachusetts
C'ity/Town of North Andover 'r
,. $,ystem Pumping Record taT i�.� y� I H i Q,
j Form 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 farm, check with yoL
local Board of Health to determine the form they use. The System Pumping Record must be submitted ti
-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, V
use only the tab q I 4 Y
key to move your Address
cursor-do not
use return
key. City/Town State Zip Code
key.
2.2hSystem Own r:
�I Name`
ream ;.
Address(if different from location)
City/Town State ip Code
C
Telephone Number
B. Pumping Record
1. Date of Pumpinga 0
Qateuantity Pumped: Gallons�
3. Component. ❑ Cesspaol(s) ptic Tank Tight Tank El Grease Trap
❑ Other(describe):
4. Effluent.Tee Filter present? ❑ Yes a If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compo ent pumped: 1
6. Systemrr6ed By:
Nam '- Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 mill st bradfor m l
i
Sign re of Mauler Date
gnature of Receiving Facility(or attach facility receipt) Date
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