HomeMy WebLinkAboutSeptic Pumping Slip - 175 STONECLEAVE ROAD 5/17/2017 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 ping date in
accordance with 310 CMR 15.351.
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A. Facility Information
Important:When Y �00
1. System Loca ion:
filling out forms tt�(
on the computer,
use only the tab
key to move your Address
cursor-do not North Andover
use the return ... .......
key. City/Town State Zip Code
VQ 2. System Owner:
"Y'
Name
Address(if different from location)
-----------
CityfTown State Zip Code
Telephone Number
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B. Pumping Record 2, Quandt Pumped:
1. Date of Pumin
..........
Date y AS
pg
3. Component: El Cesspool(s) Er"Septic Tank 0 Tight Tank n Grease Trap
R Other(describe): ................................................. ------------
4. Effluent Tee Filter present? 0 Yes El No If yes, was it cleaned? R Yes El Na
5. Observed condition of component pumped:
6 6. Ste umped By:
N e ................ Vehicle license
Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 bradford ma
......... ........
S S ature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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