HomeMy WebLinkAboutSeptic Pumping Slip - 105 SULLIVAN STREET 3/16/2017Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
IA
CE1V
6 2011
TOWN OF NON H 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:
ID 4:3 Sk \ r
Address
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3, Component:
a-- 1-
Date
111 Cesspool(s)
111 Other (describe):
4. Effluent Tee Filter present? El Yes No
5. Observed con ition of component pumped:
()(
6. Syste Pumped'By:
2. Quantity Pumped:
Gallons
Septic Tank E] Tight Tank El Grease Trap
If yes, was it cleaned? LI Yes D No
warts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
&s. mill t bradford ma
ature of Hauler
Signature of Receiving Facility (or attac
Vehicle License Number
Date
acility receipt) Date
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