HomeMy WebLinkAboutSeptic Pumping Slip - 107 SUMMER 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 fo check with your
local Board of Health to determine the form they use. The System Pumping Resubmitted to
the local Board of Health or other approving authority within 14 days from the9 11
accordance with 310 CMR 15.351. ;0ri
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A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, Ir,
use only the tab
key to move your Address
cursor-do not
use the return —----- ...............
key. City/Town State Zip Code
2. System Owner:
4:1 1 1 'U'u-0 --–-------
C
Name
tetrxn
-k(i��------- ...... .......
ss(ifdiffer—ent—frorn—location)-- . .. .. ......
..................
City/Town State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping ')...... I'll, 2. Quantity Pumped:
Date Gallons
3. Component: F-1 Cesspool(s)
Septic Tank El Tight Tank 0 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? El Yes F] No If yes, was it cleaned? El Yes F-1 No
5, Observed. ondition of component pumped:
mped By:
— --—-------------------
a e ✓ Vehicle License Number
warts Septic 58 So Kimball St Bradford Ma
Company
y's
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te
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n
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e
7. Location where contents were disposed:
1--IN I
I.,As mill st bradford ma
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ignatur, fTtatder'7 bate
. . ................
Signature of Receiving Facility(or attach facility receipt) Date
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