HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 2/14/2017 (5)Commonwealth of Massachusetts
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City/Town of North Andover
System Pumping Record
Form 4
TO\Ait\I tloRti-i ANDOVER
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:
1011, Qi)
Address
North Andover
City/Town
2. System Owner:
Name
Address (if different from location)
Cityff own
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2, Quantity Pumped:
Gallons
3. Component: Lil Cesspool(s) L Septic Tank El Tight Tank 111 Grease Trap
Er/Other (describe): 6.
4. Effluent Tee Filter present? E] Yes El No If yes, was it cleaned? 111 Yes 0 No
5. Observed copdition of component pumped:
envPu)nped By:
(/' S ewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
mi1Jijradfordd ma
igna,r of Hauler
Vehicle License Number
c
Date
Signature of Receiving Facility (or attach facility receipt) Date
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