HomeMy WebLinkAboutSeptic Pumping Slip - 1077 OSGOOD STREET 2/14/2017 Commonwealth of Massachusetts RECEIVED
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4 Z'0I I
City/Town of North Andover
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System Pumping Record TOWN Ul;04()�4,(fj jvcOVE
Form 4 HE-ALTH 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.
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A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not North Andover
use the return
key. City/Town State Zip Code
2. System Owner:
roe
_ 1 Cm
...........
A
Name
............ - - ----- ........... ..........
Address(if different from location)
...........- ----------------
City/Town State Zip Code
Telephone Number
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B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. po nt: ❑ Cessp'qol(s� El Septic Tank El Tight Tank B Grease Trap
/µ
0/
Other(describe):
4. Effluent Tee Filter present? El Yes Ej No If yes, was it cleaned? El Yes n No
5. Observed condition of compo ent pumped:
.............. ............ ..... .
6. Systq�ffmpo.TB(�.
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford-r
pa
Sig ature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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