HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 5/11/2017Important: 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 sub ' d to
the local Board of Health or other approving authority within 14 days from the pumpin
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
5S L0 \ 1100
Address
North Andover
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
State
State
100ok.v.,,,)\4\y\p‘ok.).0\10k.
Zip Code
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
5Ui1
Date
2. Quantity Pumped:
3. Component: Lil Cesspool(s) El Septic Tank D Tight Tank
,-3/C19e_ IC4
0 Other (describe):
4. Effluent Tee Filter present? D Yes LI No
5. Observed condition of component pumped:
6. System Pumped By:
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)
L0C
Gallons
El Grease Trap
If yes, was it cleaned? El Yes 0 No
Vehicle License Number
Date
Date
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