HomeMy WebLinkAboutSeptic Pumping Slip - 1030 JOHNSON STREET 1/16/2018 C60�alth of• Massachusetts
4. City/Tow' n' of North Andover
S,ystern Pumping Record
,•� Form 4 �
i
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 submittec
-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:wheri ' ,
filling out forms , 1. System Location:
on the computer,
use only the tab 3e
key to move your Address
cursor-do not
use the return C' Prawn
key. kY State Zip Code
2"` S`ystem Owner:
Name`
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
. / - }
1. Date of Pumping Date 2. uantity Pumped:
Gaflbns
3. Component: ❑ Cesspool(s) ;Septic
Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pu ed:
6. SYE m Pumped By:�
��
Name Vehicle license Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were d used:
r-2" ill st bradford 4"': s
Signature of 'a r Date
Signature of Receiving Facility(or attach facility receipt) Date
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