HomeMy WebLinkAboutSeptic Pumping Slip - 39 HAY MEADOW ROAD 12/12/2017 i
V
t G�'g
Comm;OTiwealth of Massachusetts
City/Town of North Andover
� s.ystem Pumping Record �pw�p
+, >
`may F irm 4 .q�' I&g�4 p�y, ¢P
.
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 yr
local Board of Health to determine the form they use. The System Pumping Record must be submitted t
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 Locatia
use oral the tab T
on the computer,
,1f
key to move your Address
cursor-do not
use the return itY C` n o
key. State Zip Code
2 Oystem Owner:
r
• Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pum'oing Record
1. Date of PumpingDate� � 2. Quantity Pumped:
Gallons
3. Component:' ❑ Cesspool(s) Septic Tank ❑ Tight Tank (1 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes M No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of