HomeMy WebLinkAboutSeptic Pumping Slip - 126 LACY STREET 5/11/2017 Commonwealth of Massachusetts
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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 Ing date in
coqe I
accordance with 310 CIVIR 15.351.
A. Facility Information
Important:When 1. System Location: cv��AOV'
filling Out forms
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return .......
key.
City/Town State Zip Code
2. System Owner:
.... ...... -------------------- ---------
Name
ratwn
Address(if different from location)
............................... ...............................
City/Town State Zip Code
Telephone Number
B. Pumping Record
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r— . y p
1. Date of Pumping Date 2Quantity Pumped; Gallons
3. Component: F1 Cesspool(s) Septic Tank El Tight Tank El Grease Trap
El Other(describe): .. .........
4. Effluent Tee Filter present? R Yes El No If yes, was it cleaned? El Yes 0 No
5, Observed condition of component pumped:
....... .. ........
6. System Pumped By:
. . ......... .......
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company-- 11 I --1 -------
7. Location where contents were disposed:
20 so millst bradford ma
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...............
Signature of Hauler Date
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Signature of Receiving Facility(or attach facility receipt) Date
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