HomeMy WebLinkAboutSeptic Pumping Slip - 543 FOREST 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 mu e submitted to
the local Board of Health or other approving authority within 14 days from the pum ,e in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
5t
Adsb 1
City/Town
2. System °wrier:
Name
Address (if different from location)
City/Town
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
3. Component: 0 Cesspool(s)
0 Other (describe):
-11
2. Quantity Pumped:
Septic Tank 0 Tight Tank
4. Effluent Tee Filter present? El Yes 17:1- No
5. Observed condition of component pumped:
(2-00
6. Systemdiurrridty:
Name
Stewats.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)
G lions
El Grease Trap
If yes, was it cleaned? 0 Yes 0 No
Vehicle License Number
Date
Date
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