Loading...
HomeMy WebLinkAboutSeptic Pumping Slip - 20 CHRISTIAN WAY 12/12/2017 r orrmu'arrr'inrealth of Massachusetts C ty/ Tow' n' of North AndoverOv ! ystem Pumping Record Form 4 r DBP 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 yf local Board of Health to determine the form they use. The System Pumping Record must be submittec - -the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. 1 A. Facility Information Important.When filling out forms 1. System Location: on the computer, use only the tab key to move your Address cursor-do not keythe return City/rown State Zip Code y � 2 ` S stem Owner. 4 Name': err Address(if different from location) City/rown State • _ ft Code. "telephone Number �— B. Pur"lnping Record CID1. Date of Pumping Date 2.,Quantity Pumped: Gallons 3. C omponent* ❑ Cesspool(s) E2"S'eptic Tank ❑ Tight Tank © Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Ye a If yes, was it cleaned? ❑ Yes ❑ No 5. Observed co dition of component p roped i • f 6. Syst�PGmped By: Name Vehicle License Number Stewarts Septic 58 So Kimball St Bradford Ma Company 7. Location where contents were disposed: 1 20 ho mill st bra o a Sig ature of Hauler Date ignature of Receiving Facility(or attach facility receipt) pate t5form4.doc•11/12 System Pumping Record•Page 1 of