HomeMy WebLinkAboutSeptic Pumping Slip - 2125 TURNPIKE STREET 2/7/2018 41
6,rT Wealth of Massachusetts
4. City/Tow' n' of North Andover
$ystem Pumping Record
F6rm 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 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:When'
filling out forms . 1. System Location:
on the computer,
use only the tab 7 l9
key to move your Address V
cursor-do not
use the return
key, C' /Town State Zip Code
2.*System Owner: 4
Nam6'y v It I
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping2. Quantity Pumped:
Date Gallons
3. Component' El Cesspool(s) Septic Tank El Tight Tank F-1 Grease Trap
El Other(describe):
4. Effluent Tee Filter present? El Yes 171 No If yes, was it cleaned? 171 Yes 171 No
5. Observed condition of component pumped:
6. System Pumpedttl
me Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradf6rd ma
Signature of Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of