HomeMy WebLinkAboutSeptic Pumping Slip - 333 RALEIGH TAVERN LANE 2/14/2017Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
GE E
1
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:
‘, \
Address
North Andover
City/Town
2. System 0i ner:
State Zip Code
CA
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
/--/k
1. Date of Pumping Date 2. Quantity Pumped:
-J
Gallons
3. Component: 11] Cesspool(s) Ekaeptic Tank El Tight Tank El Grease Trap
LI Other (describe):
4. Effluent Tee Filter present? El Yes Ergo If yes, was it cleaned? Ili Yes No
5. Observed condition of component pumped:
—07"—Q
6. System Pump B
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
•
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler
Vehicle License Number
Signature of Receiving Facility (or attach facility receipt)
Date
Date
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