HomeMy WebLinkAboutSeptic Pumping Slip - 2 HAY MEADOW ROAD 5/15/2017 -
Commonwealth of Massachusetts
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City/Town of North Andover
4 System Pumping Record
ev
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 farm they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the puIj i to in
accordance with 310 CMR 15.351. µ
A. Facility Information �14`ti
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Important:when t1tV6ff t6
filling out forms 1. System Location: t y C ° ti ? tett
on the computer, } �} t
use only the tab _....l..._y( 4
key to move your Address
cursor-do not North Indov
use the return
key. City/Town State Zip Code
2. System Owner:
VQ
- 1 ��
Name
r°r vn
Address(if different from location)
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CityFrown State Zip Code
Telephone Number
B. Pumping Record
ti. Date of Pumping _ �. - 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe);
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ Na
5. Observed condition of component pumped:
S e efmped By:
..... -------,,
N` me Vehicle License Number
�S ewartg-Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
._ .
ignature of Hauler Date
Si n twof-R`e ch fceiving Facility(or attach receipt) Date
�uce
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