HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 3/16/2017 (3)Important: W hen
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
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MAR 0 /{r
KH ANDOVER
DEP has provided this form for use by local Boards of Health. Other forms may r W TAVMENT
information must be substantially the same as that provided here. Before using this orm, 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:
1r-35() ljtj
Address 1
Alt)(
City/Town
2. System Owner:
Name
r-
Address (if different from location)
State Zip Code
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
()k
Date
2. Quantity Pumped:
Gallons
LI Cesspool(s) El] Septic Tank LI Tight Tank El Grease Trap
El/ Other (describe):
4. Effluent Tee Filter present? 111 Yes No If yes, was it cleaned? L Yes El No
5. Observed c ndition of component pumped:
ystem Pumped By:
-.31Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
-0-so mi adford ma
“gnature of Haule
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
L'
Date
Date
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