HomeMy WebLinkAboutSeptic Pumping Slip - 40 OXBOW CIRCLE 5/30/2017 _
Commonwealth m� ��Massachusetts
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.North Andover
System Pumping Record
Form 4
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DEP has provided this form for use.by local Boards of Health. Other forms may be used, but the
information must he substantially the name as that provided here. Before using this form, check with your
|nco| Board of Health todetermine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14days from the pumping date in
accordancewith 310CIVIR15351
A. Facility Information
Important:When j J
filling out forms 1. System Looation
onthe computer,
use only the tab _
key tomove your xuore*o � cl�r
cursor-do not �-
North Andover
use the return --key. City/Town Q,y/Towo S|we Zip Code
2. System Owner:
Name
location)'--
City/Town State C d
Telephone Number
B. Pumping Record
|
---�t|ty Punpmd:1. Date of Pumping o"�e
seUonw
3. Component: Fl Cesspool(s) eSepticTenk [l Tight Tank Fl Grease Trap
[]
Other(describe): -------------- -------
4. Effluent Tee Filter present? Fl Yes EY, No If yea, was it cleaned? R Yea El No
5. Observed conditionnfcomponentpumped:
XI
G. S d
Name Vehicle License Number
Stewarts Septic 58 So Kimball S(Bradford M
Company
7. Location where contents were disposed:
-— –---------
Sig ature of Ha ler Date
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