HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 2/14/2017 (3)Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
c
FE
14
'/017
TOWN OF NORTH 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:
3S-1 VO\ UOik
Address
North Andover
City/Town
2. System Owner:
)b\I
Name
Address (if different from location)
City/Town
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
3. Component: Lil Cesspool(s) El Septic Tank
IR11 Other (describe):
4. Effluent Tee Filter present? LI Yes 0 No
5. Observed, condition of component pumped:
6. System Pumped By:
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
adford ma
'Signature of Receiving Facility (or attach facility receipt)
0 Tight Tank
Gallons
El Grease Trap
If yes, was it cleaned? LI Yes El No
Vehicle License Number
1— s.
Date
Date
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