HomeMy WebLinkAboutSeptic Pumping Slip - 110 FOREST STREET 5/7/2018 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover
MAY 0 Y Z018
System Pumping Record -iom orNORIII MCOVER
Form 4 ,.1H DEPAV�XMENT
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 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 C M R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Locatio
on the computer, 640
use only the tab
key to move your Address
cursor-do nottJ, MA
use the return
key. City/Town State- Zip Code
2. System 00ner,
)s
Name
rerun
Address jif different from location)
47,
City/Town State Zip Code
........................
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) [Septic Tank El Tight Tank El Grease Trap
❑ Other(describe): ..........................
4. Effluent Tee Filter present? El Yes En-90---- If yes, was it cleaned? ❑ Yes 6-Ne-
5. Observed condition of component pumped: CJ
6. System Pump 7,d?y:
V1
Name Vehicle License Number
Stewart's Septoq E�8.So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 $o-Mil T-S-t--1Br-'ford,
i4twulb of Hauler Date-.W---
Signature of Receiving Facility(or attach facility receipt) Date
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