HomeMy WebLinkAboutSeptic Pumping Slip - 1935 SALEM STREET 1/16/2018 ' Co
rrarri6Wvealth of Massachusetts
City/ToWn' of North Andover
ug
, S;ystem Pumping Record
Form 4
J
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 1
accordance with 310 CMR 15.351.
A. Facility information
Important:When"
filling out forms , 1. System Location:
on the computer,
use only the tab 19 •„�. l )�
key to move your Address
cursor-do not
use the return . Rowe
key. State Zip Code
2.� System Owner:
Name':
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumpingat� 2. Quantity Pumped: Gallons
3. Cor'nponent� ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditia of co ponent pumped:
6.=eem eey: ,
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
0 so mill st bradford ma
ignature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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