HomeMy WebLinkAboutSeptic Pumping Slip - 106 ROCKY BROOK ROAD 5/10/2017 - |
Commonwealth �� Massachusetts
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City/Town
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North Andover
System Pumping Record
Form 4
DEP has provided this form for use bylocal Boards ofHealth, Other forms may be used, but the
information must be substantially the some as that provided here. Before using this form, check with your
|one| Board of Health hodetermine 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 in
accordance with 31UCk4R15.351.
-----------------A. Facility Information
Important:When
f0 1. System Location:
on the computer,
use only the tab
key tomove your Address � V- ^-
ovmor-dunw
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
Name
Address(if different from location)
City/Town cxam Zip Code
Telephone Number
B. Pumping Record
1. Date ofPumping Date2. Quantity Pumped:
Gallons
3. Component: [] Cesspool(s) [3--'Septic Tonk 0 Tight Tank 0 Grease Trap
0 Other(describe): ����------ -- ----'
4. Effluent Tee Filter present? [l Yes Fl No |fyes, was itcleaned? El Yea El No
5. Observed condition of component pumped:
80(
me Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
tin
7.. Location where contents were disposed:
20 bradord ma
S' n re of Hauler Date
Signature of Receiving Facility(or attach facility receipt) D ate
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