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HomeMy WebLinkAboutSeptic Pumping Slip - 575 WINTER STREET 1/16/2018 C0ni,m`01*ea1th of Massachusetts t 4: City/To w* n• 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 information must be substantially the same as that provided here. Before using this fa rm, 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 forrns . 1, System Location: on the computer, ��r.. kK �. use only the tab key to move your Address cursor-do not use the return 4A/) 1 ,,— key. Citylrawn State Zip Code 2*System Owner: Name` rears Address.(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record Date l 2 JCS 1. Date of Pumping ate 2. Quantity Pumped: - Gallons 3. Component°' © Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap (� Other(describe): 4, Effluent Tee Filter present? ❑ Yeso If yes, was it cleaned? ® Yes El No 5. Observed condition of component pumped: —. 6. System Pumped By: , r) 2G- Name Vehicle License Number lei Stewarts Septic 58 So Kimball St Bradford Ma Company 7. Location where contents were disposed: 20 sa st b dford ma l f - /7— Si nature of uler pate Signature of Receiving Facility(or attach facility receipt) pate t5form4.doc•11/12 System Pumping Record•Page 1 of