HomeMy WebLinkAboutSeptic Pumping Slip - 62 WILLOW RIDGE ROAD 5/30/2017 Commonwealth of Massachusetts
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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 must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping in
accordance with 310 CMR 15.351.
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A. Facility Information 2
Important:When
y'v
filling out forms 1. System Location:
on the computer,
use only the tab ...... ................................
key to move your Adc",,,I,
cursor-do not
use the return ...........
key, CityfTown State Zip Code
ren 2. System Owner:
T .. ........
Name
nxn
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Address(if different from location)
1571—ty Own" State Zip Code
Telephone Number
B. Pumping Record 2. Quantity Pumped: /oo
1. Date of PumpingDa e G'allons
3. Component: n Coss ool(s) ESeptic Tank El Tight Tank Grease Trap
El Other(describe):
"'No -1 Yes El No
4. Effluent Tee Filter present? El Yes E3 If yes, was it cleaned?
5. Observed condition of component pumped:
CC)
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6. System PumTdd By-
Na e- Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 6"mill st bradfo ma
0
Si9 nature of auler Date
............... ...........
Signature of Receiving Facility(or attach facility receipt) Date
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