HomeMy WebLinkAboutSeptic Pumping Slip - 111 BOSTON STREET 1/16/2018 -\ ,� s , tai, ,.:, • t
Com,ma'nwealth of Massachusetts
City/Town' of North Andover
w System Pumping Record
Y Farm 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 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:where
filling out 1. System / tl�(/ r
on the computer, ,, I
use only the tab -/ t �3 l"
key to move your Address
cursor-do not
use the return /Tawm
C'
key. �` State Zip Code
'2",S�ratem Own r� 44
rJ
J r
am e
t
Address(if different from location)
CityfFown State
. 0/ Zip Cede
999Telephone Number
B. Pumping Record
d.
1. Date of Pumping 'a Quantity Pumped: / �-
Gallons
3. Component:' ❑ Cesspool(s) eptic Tank ❑ Tight Tank 0 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes6No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of cornponent pumped:
6. em Pump d By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma f
Company
7. Location where contents were disposed:
0 so mill st bradford ma
tof Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record•Page 1 of