HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 2/14/2017 (2)Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
EC V
FT,I3
TOWN Oh NUR 0-1 ANDOVE
HEALTH DEPARTMENT
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:
k0 ,
Address
North Andover
City/Town
State Zip Code
2. System Owner:
-raa, \.
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
E1"6ther (describe):
1- d
Date
Ell Cesspool(s) 0 Septic Tank
MCC.)
4. Effluent Tee Filter present? ID Yes El No
5. Observed ccndition of component pumped:
arts Septic 58 So Kimball St Bradford Ma
mpany
7. Lo.cati
2050
where contents were disposed:
bradford ma
Signat e of Hauler
S' nature of Receiving Facility (or attach facility receip
2. Quantity Pumped:
11
Gallons
0 Tight Tank 0 Grease Trap
If yes, was it cleaned? 0 Yes 0 No
Vehicle License Number
(— V-1
Date
Date
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