HomeMy WebLinkAboutSeptic Pumping Slip - 130 REA STREET 2/14/2017Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
!RECEIVED
1 4 2017
TOWN Ul- Nuk 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:
Address
North Andover
City/Town
2. System Owner:
Name
Address (if different from location)
State Zip Code
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
3. Component: 1111 Cesspool(s)
El Other (describe):
2. Quantity Pumped:
Gallons
V'Septic Tank LI Tight Tank II] Grease Trap
4. Effluent Tee Filter present? El Yes El No If yes, was it cleaned? El Yes El No
5. Observed condition of CO ponent pumped:
6. 'umped By:
ewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
bradford ma
Vehicle License Number
Date
Signature of Receiving Facility (or attach facility receipt) Date
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