HomeMy WebLinkAboutSeptic Pumping Slip - 115 CRICKET LANE 4/9/2018 (4) Commonwealth of Massachusetts
City/Town of North Andover
y Pumping System Pum in Record
Farm 4 v
DEP has provided this form for use by local Boards of Health. Other forms ma� 'e'used, but the
information must be substantially the same as that provided here. Before using this form, 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 / -
key to move your Address
cursor-do not MA
use the return CitylTown State Zip Code
key.
2. System Owner:
teb
Name
rertan
Address(if different from location)
CityHown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2, Quantity Pumped: Gallons
CIO
3. Component: ❑ Cesspool(s) D16eptic 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:
C z4
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So,_Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
Signature of Hauler Date
l
Signature of Receiving Facility(or attach facility receipt) Date
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