HomeMy WebLinkAboutSeptic Pumping Slip - 315 ABBOTT STREET 1/16/2018 dornn�alth of Massachusetts ,,,
City/Town' of North Andover
System 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
local Board of Health to determine the form they use. The System Pumping Record must be subn
-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:where
filling out forms 1. System Location:
on the computer,
use only the tab r' c c J
key to move your Adi1fess
cursor-do not
use the return V do ie e 4
key. Chylrown state Zip Code 1
2�' stem Owner:
Name
Address(if different from location)
Cityrr°vun State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ' � ��� � 2. Quantity Pumped;
Gallons
3. Component' ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee f=ilter present? � Yes ❑ Na If yes, was it cleaned? [0 Yes No
5. Observed condition of component pumped:
f
Vie-
45
� .
t
6. System Pumped By:
Name Vehicle license Number
_Stewarts Septic 58 So Kimball St Bradford Ma
Company
i
7. Location where contents were disposed:
20 so fi
ills bradford ma
Signature auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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