HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 1/16/2018 (4) C `rTiMbivea[th of Massachusetts
4: CEty/Town' of North Andover
S,ysfem Pumping Record
Form 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:When
filling out fom7s 1. System Location:
on the computer, ; I ✓
use only the tab , U u 1{ 4 I
key to move your Address
cursor do not
use the return C' /town
key. 'ty State Zip Code
-2*Sstem Owner:
1b
Name'
�nm • a
Address(if different from location)
Cityfrown State Zip Code
"telephone Number
B. Pumping Record
Id- 1 ,(h)
1. Date of Pumping Das 2. Quantity Pumped: Gal
lons
3. Component:' ❑ Cesspool(s) ❑ Septic Tanis ❑ Tight Tank Er-Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By: n n
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford.ma
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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