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HomeMy WebLinkAboutSeptic Pumping Slip - 97 WINDKIST FARM ROAD 2/7/2018 dom Omealth of Massachusetts �. C tyffovi n' of North Andover W $ysterrr 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 yR J local Board of Health to determine the form they use. The System Pumping Record must be submitted k „ the local Board of Health or other approving authority within 14 days from the pumping date in rdance with 310 CMR 15.351. 1w �w A. Facility Information Important.nt.when' r filling out farms 1. System Location: on the computer, / �/ r use only the tab [ �i key to move your Address cursor-, no# � Use the reteturn key. City/Town State Zip Code "2.* 9�s4e Owner: Name`s` Address(if different from location) City/Town State Zip Code "telephone Number B. Pumping Record 1. Date of Pumping D --- 2. Quantity Pumped: Mons - 3. Component- ❑ Cesspool(s) eptic Tank ❑ Tight Tank © Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? es ❑ No i 5. Observed condition of component pumped: " . 6. Syst� Pumped By: Name Vehicle Lic rise Number Stewarts Se tic 58 So Kimball St Bradford Ma Company 7. Location where contents were disposed: 20 so II st bradford ma S ure of a Date Signature of Receiving Facility(or attach facility receipt) Date t5forrn4.doc•11/12 System Pumping Record•Page 1 of