HomeMy WebLinkAboutSeptic Pumping Slip - 366 FOREST STREET 1/16/2018� m
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Com;monwealth 4( Massachusetts
REM
Cityffown' of North Andover
S,ystem Pumping-Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the I
information must be substantially the same as that provided here. Before using this form, check with y 1
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 314 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
key.usethe return
cityrrown State Zip Code
�a
2 System Owner:
Name
Address(if different from location)
Cityrrown State Zip pCCod
T-,;ephone Number
B. Pumping Record
1. Date of Pumping / fQuantity Pumped:
Date Gallons
3. Component~ ElCesspool(s) yeoiricTank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ED] Yes
a if yes, was it cleaned? ❑ Yes ❑ No
5. 2bserved con ' ' of om onent pumped:
6.tys 'Pumped By
m Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where conte were disposed:
2 o mill st bradf'rd ma
Sig ature of Hauler Date
ignature of Receiving Facility(or attach facility receipt) gate
t5form4.doe.11112 System Pumping Record•Page 1 of 1