HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 12/12/2017 (2) ` Corr, inf,01*ealth of Massachusetts RicrMVU,
Oity/Tow' n' of North Andover
F�R
ystern Pumping Record
F6rm 4 t,�EALTK 0ER*1'UMEN'f
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 15.351,
A. Facility Information
Important:When
filling out form§ , 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return
key, Cftyfrown State -9p Code
`2:"' System Owner:
(y
Name'.,
Address(if different from location)
Cityfrown State Tip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Componehts El Cesspool(s) ❑ Septic Tank ❑ Tight Tank El Grease Trap
El Other(describe):
5 L",,
z
4. Effluent Tee Filter present? 0 Yes n No If yes, was it cleaned? F] Yes El 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 bradf6rd,ma
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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