HomeMy WebLinkAboutSeptic Pumping Slip - 57 SOUTH CROSS ROAD 1/16/2018 CW"mmdnWealth of Massachusetts
w: Clty/Touvn of North Andover
.ystem Pumping Record
Form 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 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 forms . 1. System Locatio r
on the computer,
y (
ab
key eto e only the t our Address
& F
y r
cursor-do not
use the return
key. City/Town State Zip Code
2 ` System Owner: 44
�l Vey e
Name`s
Address(if different from location)
City/rown State Zi Cod
"I elephone Number
B. Pumping Record
1. Date of Pumping Date Quantity Pumped:
Gallons
3. Component.• ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye o If yes, was it cleaned? n Yes ❑ No
5. Observed condition of compon nt pumped:
6. System rriped By:
Name Vehicle license Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
I
7. Location where contents were disposed: 1
20 so mill st bradford m
U5
Sign ee Hauler Date
S' nature of Receiving Facility(or attach facility receipt) Date
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