HomeMy WebLinkAboutSeptic Pumping Slip - 1015 JOHNSON STREET 5/8/2017Important: When
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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 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 date in
accordance with 310 CMR 15.351.
A. Facility Information
System Location:,
AddresslS itr)Saf)
4anda\ICS
City/Town
2. System Owner:
State
Zip Code
Name ioLLM
Address (if different from ocation)
City/Town
State
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping
3. Component:
Date
1111 Cesspool(s)
El Other (describe):
2. Quantity Pumped:
El Septic Tank El Tight Tank
,_c)
ijns
El Grease Trap
4. Effluent Tee Filter present? El Yes
No If yes, was it cleaned? El Yes El No
5. Observed conditi n of component pumped:
6. System Pump d
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
Date
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