HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 2/14/2017Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
0
4 nil
IOWN 6404-..cH ANDOVER
liU,LTHDEPARTMENT
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
1. System Location:
\ 1
Ad ress
North Andover
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
Cr Other (describe):
I B I
Date
2. Quantity Pumped:
Lil Cesspool(s) El Septic Tank
:SAIL
4, Effluent Tee Filter present? 111 Yes LI No
5. Observed condition of component pumped:
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 o filill,, st bradford ma
,"Signature of Receiving Facility (or attach facility receipt)
Jc
Gallons
D Tight Tank D Grease Trap
If yes, was it cleaned? 111 Yes Ell No
Vehicle License Number
Date
Date
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System Pumping Record • Page 1 of 1