HomeMy WebLinkAboutSeptic Pumping Slip - 267 OLD CART WAY 5/19/2017| -- -'-
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Commonwealth of Massachusetts
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City/Town of
System Pum��~� Record
'
Pumping `
Form 4
DEP has provided this form for use by local Boards ofHealth. 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 H | h or otheri h i within 14 days from the pumpin �
accordance with u/v `,/v/n 15,351. �
A. Facility Information
Important:When
filling Out forms /. System Location:
onthe computer,
use only the tab .............
key tomove your Address
cursor-do not
North Andover
use the return -----------___�������
k^y. City /own «umm Zip Code
2. System Owner:
VQ qa
Name
-------- - -------------
Address(if different from location)
City[rown State Zip Coep
Telephone Number
B. Pumping Record
6-0
1. Date ufPumping bate Quantity Pumped: Gallons
3. Component: || Cesspool(s) "skz Tank F-1 Tight Tank [l Grease Trap
[] Other(describe): ..............
4. Effluent Tee Filter present? 0 Yes O No (fyes, was itcleaned? [] Yes [l No
5. Observed 99ndition of component d
_. -7, LNamd-1 Vehicle License Number
Stewarts Septic 58 So Kimball S Br dford Ma
or
ocation L000donwhere contents were disposed:
J220s ill st bradford
ill St
of Haule
Signatu e 7r Date
ure of Receiving Facility(or attach facility receipt) Date
Sign of Re
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