HomeMy WebLinkAboutSeptic Pumping Slip - 89 GRAY STREET 12/12/2017 bm,rnoo'Wealth of Massachusetts ��,�� ° Pa� �,^�,��C
City/T'ow' n• of North Andover
!�ystern Pumping Record
F6 m ^Y!
J
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 submittec
-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
ruing out farms . 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return Gitylrown
key. State Zip Code
2 System Owner:
(6) M c' Lcj r
Name'.,
aam
Address(if different from location)
CivTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping f�—✓'36 1
p g Date 2. Quantity Pumped: Gallons
3. Component.' ❑ Cesspool(s) ®eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
C
6. System Pumped By:
C
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