HomeMy WebLinkAboutSeptic Pumping Slip - 315 SOUTH BRADFORD STREET 8/12/2016 'C'\ Commonwealth of Massachusetts
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System Pumping Record NORTH ANDOVER
Form 4
DEF has provided'this form for use by local Boards of Wealth. Other forms may be used, but the
information must be substantially the same as that provided here_ Before using this farm, check with your
local Board of Wealth to determine the form they use_ The System Pumping Record must be submitted to
the focal Board of Health or other approving authority within 14 days from the pumping date in
accordance with 313 CMR 15.351.
A. Facility Information
Important:
when fitting out I. System Location:
Corms 1 � �
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cursor-do not — — �� U
use the return City;Town State ip code
key. 2. Syste Owner:
Name
�P Address(If different from location)
City/Tpwn State �cpqg
T9f h n itiFUmber �..._..,'—..,.., — --B. Pumping Record
'I, Date of Pumping p"}.�1J �`` 2. Quantity Pumped:
3. Type of system: ❑ Cesspooks) El Septic Tank ❑ Tight Tanis Grease Trap
❑ Other(describe),
4. Effluent Tee Filter present? ❑ Yes No Ef yes, was it ciaaned? ❑ Yes ❑ No.
5. Condition of System,
6. System Purnped ey; lCY:i i 1'�rw!' 114'11 11lSi� fold
163 Western Ave__
Name V2tlicle License Nurrlber
dmpany
7. Location where contents were disposed: STEWARTS SEPTIC SERVICE
58 SOUTH KIMBALL ST.
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Stgrta#ure of Hauler - a e
$igRature pf Receiving Facility Date
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