HomeMy WebLinkAboutSeptic Pumping Slip - 12 WINTERGREEN DRIVE 5/10/2017Important: 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 pu ping date in
accordance with 310 CMR 15.351.
A. Facility Information
1, System Locatio
Address
\\ inc131
city IT own
2. System Owner:
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
Date
State Zip Code
State Zip Code
Telephone Number
2. Quantity Pumped:
Gallons
3. Component: 111 Cesspool(s) Septic Tank LI Tight Tank El Grease Trap
E] Other (describe):
4. Effluent Tee Filter present? LI Yes Lil No If yes, was it cleaned? El Yes El No
5. Observed c ndition of component pumped:
Pumped By:
tewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
Date
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