HomeMy WebLinkAboutSeptic Pumping Slip - 61 ABBOTT STREET 6/7/2018 Commonwealth
��������[�y]\�����"u / `�^
City/Town of No. Andover, MA
System ump~ng Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms ��7�be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
(ooe| Board ofHealth to determine the form they use. The System Pumping Record must besubmitted to
the |onm| Board of Health orother approving authority within 14 days from the pumping date in
accordance with 31OCMR 1b.351.
A. Facility Information
Important:When
filling out forms 1System Location:
onthe computer,
use only the tab
key tumove your 8ddemo
cursor'uonot
K8 O1045
use the mtum North
key. City/Town State Zip Code
2. System Owner:
Q `
Name
Address(if different from location)
uxyf/mwn State Zip Code
Telephone Number
B. Pumping Record
1. Date nfPumping Date 2. Quantity Pumped: Gal mna
3. Component Fl Cesspool(s) Eq'SepticTenk R Tight Tank Fl Grease Trap
E] Other(describe):
4. Effluent Tee Filter present? Fl Yee [l No If yes, was it cleaned? Fl Yes D No
5. Observed condition of component pumped:
_ _'-'—.. Pumped By:
�j
Name Vehicle License Number
Stewart's Septic
Company
7, Location where contents were disposed:
20 So. Mill SBradford,
§/gnauuveu*Hauler DoUa
Signature mReceiving Facility(or attach facility receipt) Dam
t5form4.dvn` 11/12 System Pumping Record^Page 1of1