HomeMy WebLinkAboutSeptic Pumping Slip - 1560 SALEM STREET 5/15/2017Important: 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 g date in
accordance with 310 CMR 15.351. riteCr
A. Facility Information
1. System Location:
Address
North Andover
City/Town State
2. System ,Owner:
Name
Ccu i)O0e1 1
10\ii\itAl PAiDONEP,
VA4)PAIAtk.Vc
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
3, Component: 111 Cesspool(s) t,K.,Septic Tank
El Other (describe):
4. Effluent Tee Filter present? 11 Yes
5. Observed condition of component pumped:
6. Syste
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Pumped,By:
Company
7. Location where contents were disposed:
20 so mill bradf d ma
Signature of Receiving Facility (or attach facility receipt)
Gallons
El Tight Tank 111 Grease Trap
If yes, was it cleaned? Lil Yes Eleo
Vehicle License Number
Date
Date
Lt
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