HomeMy WebLinkAboutSeptic Pumping Slip - 2201 SALEM STREET 5/7/2018 Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health, Other forms may IbVW44'&' 4t e°
information must be substantially the same as that provided here. Before using this I 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, n k P
c.
use only the tab
key to move your AtsS
cursor-do not MA
use the return
key. CityfTown State Zip Code
2. System Owner:
Name
aeetarvn
----------
Address(if different from location)
.............-
City/Town State Zip Code
Telephone Number
B. Pumping Record
1'b
1. Date of Pumping je 2. Quantity Pumped:
Gallo'ns j_ L _
3. Component: Fj Cesspool(s) Septic Tank n Tight Tank F-1 Grease Trap
M Other(describe): -----------
4. Effluent Tee Filter present? E] Yes If yes, was it cleaned? E] Yes /o.-go-,
5. Observed condition of component pumpe
—---------
6. System P.u 77 d By:................
Name Vehicle Lice se Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Locationwhefe contents were disposed:
2b,S'6"Mill St., adford, MA
Signaftire of-Hauler Date..
Signature of Receiving Facility(or attach facility receipt) Date
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