HomeMy WebLinkAboutSeptic Pumping Slip - 733 TURNPIKE STREET 1/19/2016 �L\ Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
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 CMR 15.351.
A. Facility information
Important:
When filling out 1 System Location:
forms on the
computer,use
only the tab key Addresp
to move your N
OAN
cursor-do not State Zip Code
use the return '
CityfTown
key.
2. Sy Owner:
Name
Address(if different from location)
City/Town State Z Code
TeIep5hnNtmtb'er
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank D16'rease Trap
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes
5. Condition of System'.
6. System Pumped By:
Vehicle License Number
Company
7. Location where contents were disposed: STWITS SEPTIC SERVICE
-. --SO SOUTH-KlWI3ALL-ST:
-----
BRADFORD, MA 04-835
Signature of Hauler D97a.Le
8 372.7471
Signature of Receiving Facility Date
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