HomeMy WebLinkAboutSeptic Pumping Slip - 600 SHARPNERS POND ROAD 5/22/2017 �
Commonwealth nfMassachusetts
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City/Town������ `�/ North Andover
System Pum -~ng 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 ofHealth urother approving authority within 14days from the pumping date in
accordance with 31UCK4R15.351,
A. Facility Information |
Important:When
filling out forms /. System �
onthe cpmputer,
use only the tab
xoymmuvmyour Address `
cursor-do not
North Andover
use the return City[Fown —
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key. ��
2� System Owner:
Name
TW4 U,
Address(if different from location)
cdyfTmwn State Zip Code
fele yhvnaNumbor
B, Pumping Record
1. Date ofPumping 2. Quantity Pumped:
3. Component: [l Cesspool(s) �(SeptinTank Fl Tight Tank El Grease Trap
El Other(describe): --- -------
4. Effluent Tee Filter present? [] Yes [-3' No |fyes, was it cleaned? El Yes F] No
5. Observed conditipn of component d:
--------------
O. SmPu
ame Vehicle License Number
.Stewarts Sep ic 58..So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill etbnmdford ma
.............
Signature of Hauler Date
Signa lure m/ee**ivinqFu*i|i�(matvmhfa*i|it'nweipt) Dpw
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