HomeMy WebLinkAboutSeptic Pumping Slip - 1627 OSGOOD STREET 5/3/2017 Commonwealth �� Massachusetts
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City/Town of
North
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 hero. 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 ofHealth orother approving authority within 14days from the pumping date hm
accordance with 318 {}K4R15351
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A. Facility Information
Important:When
filling out forms 1. System Location:
vnthe computer,
use only the tab
�9tmmove your Address - ^~-
cursor-do not
North Andover
use the return
key. oi/y[ Statemwn �, v Zip Code
2. System Owner:
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Address(if different from|numUon)
CityfTown State S/ato onnvdo
telephone,Number
B. Pumping Record
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1. Date ofPumping Date ~- 2. Quantity Pumped: ��N»m,
3. Component: Fl Cesspool(s) Septic Tank El Tight Tank Fl Grease Trap
El Other(describe):
4. Effluent E0oentTee Filter present? El Yes El No If yes, was it cleaned? [l Yes [l No
S. Observed condition ofcomponent pumped:
-. _'_-_m P—m,-__'.
mmm� -----' Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford M
Company
7. Location where contents were disposed:
20 so mill atbradfon] ma
Signature vfHauler Date
Signmure nf—R*:vi�ngFaoi|ity(or attach facility receipt) Date