HomeMy WebLinkAboutSeptic Pumping Slip - 165 INGALLS STREET 5/22/2017 Commonwealth nfK�Massachusetts
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City/Town of
North
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 mmai be substantially the oema 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 her approving authoritywithin 14 days from the pumpin te in
accordance with 310 CIVIR 15,351.
A. Facility Information 01"110;
Important:When a^
filling out forms 1. System Lo
on the computer,
use only the tab
key to move your xudmoa �)
mrau,-do not
North Andover
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key, Cay[Town State Zip Code
2. System Owner-
C,
Name
Address(if different from location)
City/Town State Zip Code
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
-bate Gallcrns
3. Component: F-1 Cesspool(s) Lt]^S*pUcTank Fl Tight Tank [7 Grease Trap
[] Other (describe): '---------
4� Effluent Tee Filter present? [] Yes [1]^�o If yes, was it cleaned? [l Yeo 0 No
5. Observed condition of componentpumped:
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8. SystemP
Name Vehicle License Number
S�v� G So Kimball St Bradford Ma
Co I '
7. Location where contents were disposed:
20so mill »tbradford ma