HomeMy WebLinkAboutSeptic Pumping Slip - 65 BRIDGES LANE 1/16/2018 COrr(r�alth of Massachusetts
4.
City/To W' n* of North Andover
°�°.. System Pumping Record
1
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 submitter
-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 form§ 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not I
key. return C�A)o C! ()
key. State Zip Code
2.* S�stem Owner:
° Name's
Address(if different from location)
Cityfrowm State Zip Code
Telephone Number
B. Pumping Record
/1
�� ". .. -
1. Date of Pumping Date 2 Quantity Pumped:
Gallons w.
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 pumpr:
_ C—
. S st rn cp
Pu
ped By:
6y
Name— Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were;d sposed:
20-'s6-rrill t bradford a'
"Sig at re of auRe Date
Signature of Receiving Facility(or attach facility receipt) Date
t5forrn4.doc•11112 System Pumping Record•Page 1 of