HomeMy WebLinkAboutSeptic Pumping Slip - 1430 GREAT POND ROAD 1/16/2018 4
Co`m 'jc' 1wealth of Massachusetts
City/Town' of North Andover
.ystern Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the 1
information must be substantially the same as that provided here. Before using this form, check with yt
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 Location:
on the computer,
use only the tab ,
key to move your Address
cursor-do not /Vd 4
7 t,'VU/1
use the return
key. City/Town State Zip Code
' '2.* System Owner:
ukw,
Name'
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
'
d� /.
1. [late of Pumping gate -- 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:
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 Date
Signature of Receiving Facility(or attach facility receipt) Date
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