HomeMy WebLinkAboutSeptic Pumping Slip - 279 BOXFORD STREET 5/30/2017 Commonwealth nfMassachusetts
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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 must be submitted to
the local Board of Health or other approving authority within 14 days from th ping date in
a^°''da''^e with 3'" CIV'` 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
nnthe computer,
use only the tab
koy(omove your xuumaa
numv,'do not
North Andover
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City/Town s1�n Zip Code
2. System Owner:
Name
Address(if different from location)
Citpr*=o State Zip Code
Telephone Number
B. Pumping Record
1. Date ofPumpiog2Date . Quantity
�
Gallons
3. Component: El Cesspool(s) ��'SoptioTonk [l Tight Tank F-1 Grease Trap
[] Other(describe): --------- --------
4. Effluent Tee Filter present? n Yes |fyes, was it cleaned? El Yes [l No
5. Observed condition ofcomponent pumped:
---
6. System Sysham Pumpmd B
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford M
Company
7. Location where contents were disposed:
20 so mill ntbrodford ma
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Signature mHauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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