HomeMy WebLinkAboutSeptic Pumping Slip - 754 BOXFORD STREET 2/14/2017Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
R
l'113 1 4 ?Oil
TOWN 0.F NOKIH 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:
S-1-1 a).04t
Address
North Andover
City/Town
2. System Owner:
State Zip Code
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
Date
)
2. Quantity Pumped:
111 Cesspool(s) EKS'eptic Tank
111 Other (describe):
4. Effluent Tee Filter present? LI Yes 111 No
5. Observed c ndition of component pumped:
Gallons
Ell Tight Tank [1] Grease Trap
If yes, was it cleaned? II] Yes 1:11 No
tewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20-se-mUI st bradford ma
1
ature of Hauler
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
Date
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