HomeMy WebLinkAboutSeptic Pumping Slip - 10 LACY STREET 3/16/2017Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
RECEIVE
KAn 2017
TOWN OF NOKIH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Otherforms 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:
11/4,0,
Addrn y\
City/Town
2. S tem Owner:
CL)6 (AL
Name
Address (if different from location)
Cityfrown
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
3. Component: 111 Cesspool(s) Septic Tank
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes
6dlons
0 Tight Tank 0 Grease Trap
No If yes, was it cleaned? 0 Yes 0 No
5. Obswed condipon of component pumped:
6. System Pumped By.•
Name
Stewarts Septic 5 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler
Signature of Receivirlg Facility (or attach facility receipt)
Vehide Licens
Date
Date
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