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HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 2/7/2018 (3) dommiMlWealth of Massachusetts City/To Wn' of North Andover h. System 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 submitte( "the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 OMR 15.351. A. Facility Information Important:Wh filling out form,§ 1. System Location: on the computer, use only the tab � � I✓ / key to move your Address cursor-do not' use the return CWrown State Zip Code key. � 4 2 k 8' ,,Aem Owner: 4 Name', Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component - © Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap `> (� Other(describe): I )ao c ...._.. ,,..••. 4. Effluent Tee Filter present? M Yes ❑ No if yes, was it cleaned? F1 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 Hauler Date Signature of Receiving Facility(or attach faollity receipt) Date t5form4.doc•11/12 System Pumping Record.Page 1 0