HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 1/16/2018 Commonwealth of Massachusetts
City/Town' of North Andover
. System Pumping Record
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DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
i
information must be substantially the same as that provided here. Before using this form, check with yoc
local Board of Health to determine the form they use. The System Pumping Record must be submitted ti
-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 I. System Location:
on the computer,
use only the tabs?../ 16
key to move your Address
cursor-do not
use the return
No' AJ4-v4I
key. City/Town State Zip Cade
2 Oystern Owner'
rab
kite
Name`
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Address(H different from location)
City/Town State Zip Code
Telephor,��Number
B. Pumping Record
1. Date of Pumping Date .. „ Yom/ 2. Quantity Pumped: Gallons
3. Component. ❑ Cesspool(s) ® Septic 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:
6. System Pumped By.
00)1
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 pate
Signature of Receiving Facility(or attach facility receipt) Date
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