HomeMy WebLinkAboutSeptic Pumping Slip - 25 ORCHARD HILL ROAD 5/31/2017 Commonwealth m� K� �
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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 besubstantially the same as that provided here, Before using this form, check with your
|uoa| Board of Health to determine the form they use. The System Pumping Record must be submitted to
the |ooe| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310CK4R 15.351. m����m:~ -
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A. Facility Information
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North Andover
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Telephone Number
B. Pumping Record
1� D�ba of Pumping "bate Quantity Pumped:
3. Component: El Cesspool(s) icTonk El Tight Tank Fl Grease Trap
E] Other(describe):
4. Effluent Tee Filter present? Fl Yes [R-1{6 If yes, was it cleaned? �� Yes F-1 No
5. ObmemedoondiUonofunmponentpumped-
8. System Pu ed B
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford M
Company
7. Location where contents were disposed:
3Ooomill otbradfordmo
Signature of Hauler Date
Date
Signature of Receijig Fa i or attach facility receipt)
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