HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 5/30/2017 Commonwealth of Massachusetts
City/Town of 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 Health to determine the form they use. The System Pumping Record mN submitted to
the local Board of Health or other approving authority within 14 days from the pua,,-11 e'i n
accordance with 310 CMR 15.351.
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A. Facility Information
Important:When
on the computer,
filling out forms 1 System Location:
use only the tab — D- ........
key to move your Address
cursor-do not North Andover
use the return
key. Cityfrown state Zip Code
2. System Owner: t
Name
.... ........ ---- --------
Address(if different from location)
- ----- ------------------------- -----------------
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City[Town State Zip Code
Telephone Number
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B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: El Cesspool(s) F1 Septic Tank F1 Tight Tank 4- easeTrap
El Other(describe): —- -- -- ----------
4. Effluent Tee Filter present? ❑El Yes U-N'0" If yes, was it cleaned? ® Yes E] No
5. Observed I ondition of component pumped:
6. 'Syste mpe ,9y:
Na
—lopl -----------
Vehicle License Number
S,/ewarts Septic 58 So Kimball St Bradford Ma
Company
7. Locati where contents were disposed:
20 s Mi!JI'st bra&o,, ma
gnat 0 'aul Date
...............
Signature of Receiving Facility(or attach facility receipt) Date
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