HomeMy WebLinkAboutSeptic Pumping Slip - 89 DUNCAN DRIVE 5/30/2017 Commonwealth of Massachusetts
City/Town �
�����Y " {]��yl [�n North Andover
System Pumping Record �
Form 4
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 H | h to determine the form h The System Pumping rd mus be submitted
the local Board of Health or other approving authority within 14 days from the p in
accordance with 310 CMR 1U51.
A. Facility Information
*`'
Important:When �
filling out forms 1. System Location:
omthe computer,
use only the tab
key tomove your Address
cursor-do not
North Andover
use the return ----- ���--------------- ��--��----'------
key. Qtw7uwm State Zip Code
2. System
VQ I ,I'(OAC
m�mo '------------�--�----------'---------�
- .
City/Town cume Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2, Quantity Pumped:
Gallons
3. Component: F-1 Coaapoo|(m) [E~Septic Tank El Tight Tank [l Grease Trap
n Other(describe): -----------------------------------
4. Effluent Tee Filter present? [l Yes Fl No |fyes, was itcleaned? El Yes E7 No
S. 0boen/edndidonnfcomponent pumped:
-�l�----------------------
6. Sy5temrPumped By:
e Vehicle License Number
'_gt�w arts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
0 so mill st bradford ma
Date
nature of Hauler
Signature of Receiving Facility(or attach facility receipt) Date
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