HomeMy WebLinkAboutSeptic Pumping Slip - 4 LACY STREET 1/16/2018 Conirri�6wealth of Massachusetts
_. City/Town' of North Andover
System Pumping Record IR
Form 4 U • t,� k�i���.b�r
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 yoL
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 Location:
on the computer, C '
use only the tab _Ad
key to move your dress
cursor-do not
use the return
key. City/Town State Zip Code
2.* Oystern Owner:
� i
C`C)U
� 7 Name
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping C` 2. Quantity Pumped:
Date Gallons
3. Component- ❑ Cesspool(s) EVSeptic Tank ❑ Tight Tank El Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped: i
6. System Pumped By: r�
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
i
i
Signature of Hauler Date
i
Signature of Receiving Facility(or attach facility receipt) Date
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