HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 1/16/2018 (2) , orrmawealth of Massachusetts
C'ity/Tow' n' of North Andover
❑stem Pumping Record
Form 4
t
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:when
filling out forms 1. System Location:
on the computer,
use only the tab I�y7 �111�J
key to move your -Address
cursor-do not
use the return i� /T awn
key. ty State Zip Cade
'2 Syatem Owner:
Af
Names
lGL171 r „�
Address(if different from location)
CiWTown State Zip Cade
Telephone Number
B. Pumping Record
1. Date of Pumping
p g pate 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): `al (
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 bradfard ma
Signature of Hauler Da{e
Signature of Receiving Facility(or attach facility receipt) Date
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