HomeMy WebLinkAboutSeptic Pumping Slip - 373 SALEM STREET 1/16/2018 (2) A. 9
om:monwealth of Massachusetts
City/Tow" n' of North Andover
M System Pumping Record
R 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 farm, check with yr
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'
on the computer,
f
filling out forms . 1. SystemLocation:
use only the ab /3r,�,
key to move your Address
cursor-do not
use the return C' /Town
key. State Zip Code
System Owner: 44
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
dl
1. Date of Pumping
Date�.... .... Gallons
� 2. Quantity Pumped: 6
3. Components ❑ Cesspool(s) O''Septic Tank ❑ Tight Tank [] 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:
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 Mauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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