HomeMy WebLinkAboutSeptic Pumping Slip - 173 RALEIGH TAVERN LANE 1/16/2018 . �
' COrir �alth of Massachusetts
lugCity/Tow' n' of North Andover
,yst m Pumping Record
F6rm 4
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 yot.
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 . 1. System Location:
on the computer, / / r
use only the tab d
key to move your Address
cursor-do not
kuseereturn
y. Citylr own State Zip Code
Y
t
2 Tk S�stem Owner:
Name
raasn , �
Address(if different from location)
Citylrown State ) Zip Code
Telephone Number
B. Purnoing Record
1. Date of PumpingDt` ` �. uantity Pumped: Gallons
l✓
3. Component:' ❑ Cesspool(s) '`eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component p ped:
6 '
6. SystemPuml5ed By:—
Namer Vehicle license Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company i
I
7. Location where contents were disposed:
2 so mill radf d ma
Si ature allaule Date �
Signature of Receiving Facility(or attach facility receipt} Date
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