HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 2/7/2018 (5) r COMMM"4wealth of Massachusetts
I .UCity/Town' of North Andover
lip 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
1local Board of Health to determine the form they use.The System Pumping Record must be submitte< 1
die local Board of Health or other approving authority within 14 days from the pumping date in
? Y\ , ,`tccordance with 310 CMR 15.351.
i A. Facility Information
Important:Wheri
filling out forms .. 1. System Location:
on the computer, 1 !
use only the tab ` w / C i �oUJ J
key to move your -Address
cursor-do not.
use the return City/1 own
key, State Zip Cade
F
2:""5'ystem Owner: �
Name':
l9Q71! r e 3
Address(if different from location)
CRYlTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Carnponent� ❑ 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. l
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 facility receipt) Date
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