HomeMy WebLinkAboutSeptic Pumping Slip - 35 WOODBERRY LANE 4/9/2018 COM
Mbl*ealth of Massachusefts
City/Tow' n' of North Andover
N )
ystem Pumping Record
Form 4 or-vo?�Tl-�P't )9v[Jk
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 submitted
-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
key to move your .,Address
cursor-donot
Use the retu. AJI) //return
(40
key. CftyfTown State Zip Code
8!Vatern owner:
Name'.-
Address(K different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Re6ord
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component-, ❑ Cesspool(s) B-S--eptic Tank El Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? El Yes n No If yes, was it cleaned? Ej Yes El No
5. Observed condition of component pumped:
6• -�7�7f-4)
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
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