HomeMy WebLinkAboutSeptic Pumping Slip - 226 ABBOTT STREET 5/26/2017 Commonwealth of Massachusetts
-- W City/Town of North Andover
a
aSystem 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 pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When � .'•3
filling out forms 1. System Location:
on the computer,
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use only the tab ( ,..TJ ��!'�-�... .J_...... ....._... .
key to move your Ad ress
cursor-do not North Andover
use the return -
key. City/Town State Zip Code
d
O
2. System Owner:
ca
- '1. -
Name
rrnxn
Address(if different from location)
City/Town State _ 7-ip Cade
Telephone Number
B. Pumping Record
1. Date of Pumping ~ . 5 -- Quantity Pumped: Jb
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes E"ZNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
-&
6. Syst Pumped B
J . IS
Na e Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
F --�
)Signatire of Ha'er _ Dateore of Receiving Facility(or attach facility receipt) Date
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