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HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 3/12/2018 (4) Commonwealth of Massachusetts City/Town of North Andover SY�terv>I Pumping p g Rec©rd -- w Farm 4 DEP has provided this form for use by local Boards of Health. Other forms m ,pb6 dA&the information must be substantially the same as that provided here. Before using 69 orm, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to 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 3t key to move your Address cursor-do not MA use the return -- key. City/Town State Zip Code 2. System Owner: VQ Name Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record d 1, Date of Pumping Date Z 2. Quantity Pumped: da-Ions 3. Component: ❑ 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: 6. System Pumped By: Name Vehicle License Number Stewart"sSeptic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. MITI St., Bradford, MA Signature of Mauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1,