HomeMy WebLinkAboutSeptic Pumping Slip - 1077 OSGOOD STREET 2/7/2018 y R
! �mmc lwealth of Massachusetts
City/Towri of North Andover
. ,ystern Pumping Record
Firm 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 submitter
-the local Board of Health or other approving authority within 14 days from the pumping date in
of
accordance with 310 OMR 15.351.
A. Facility Information
Important:WC7eri
filling out formt .. 1. System Location:
on the computer,
use only the tab 1 /6 r - 3 &oo
key to move your Address
cursor-do not'
use the return Citylrown
key. State Zip Code
2"'System Owner: 44
Name`s
. ria r
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Red®rd
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component:` ❑ Cesspool(s) ❑ 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
• i
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t6form4.doc•11/12 System Pumping Record•Page 1 o