HomeMy WebLinkAboutSeptic Pumping Slip - 350 HOLT ROAD 2/7/2018 " 60ai�yftWealth of Massachusetts
M. City/Town' of North Andover
4ystem 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
N) accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out formt . 1 System Location:
on the computer,
use only the tab 3 60 kl 6�d
key to move your Wd—dress,
cursor-do not
use the return
key. Cftyfrown state
Zip Code
2.*System Owner:
��_= Name'.,
Address(W different from location)
CCity/Town State Zip Code
Telephone Number
B. Pumping Re6ord
1. Date of Pumping 1 -31 /Z 2, Quantity Pumped:
Date Gallons
3. Component` ❑ Cesspool(s) Septic Tank n Tight Tank ❑ Grease Trap
0 Other(describe):
4. Effluent Tee Filter present? El Yes M No If yes, was it cleaned? n Yes n Na
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 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