HomeMy WebLinkAboutSeptic Pumping Slip - 701 FOREST STREET 5/18/2017Important: 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 bmitted to
the local Board of Health or other approving authority within 14 days from the pup_ e in
accordance with 310 CMR 15,351.
- ,
A. Facility Information
1. System I_ cation:
l 01 t rtS3
Address
North Andover
City/Town
2. System ./)r1er:
State Zip Code
\\c‘ 1()
Name
State Zip Code
Telephone Number
1. Date of Pumping Date
i_577C5r- /7 2. Quantity Pumped:
Gallons
75-Z)CD
3. Component: LI Cesspool(s) 1:11-"S-e-ptic Tank 0 Tight Tank 0 Grease Trap
Address (if different from location)
City/Town
B. Pumping Record
0 Other (describe):
4, Effluent Tee Filter present? 111 Yes Eft\lo
5. Observed condition of component pumped:
d6. System Pumped y:
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
If yes, was it cleaned? 0 Yes 0 No
Vehicle License Number
Signature of Hauler Date
Signature ri.g Facility (or attach facility receipt) Date
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