HomeMy WebLinkAboutSeptic Pumping Slip - 345 BERRY STREET 7/12/2017Important: When
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Wan
Commonwealth of Massachusetts
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 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 pum• date in
accordance with 310 CMR 15.351.
A. Facility Information
1 System Location:
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Address
North Andover
City/Town
2. System Owner:
O Vta,U,
Name
State Zip Code
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
2. Quantity Pumped:
Date
Gallons
Li Cesspool(s) a/Septic Tank 111 Tight Tank Lil Grease Trap
El Other (describe):
4. Effluent Tee Filter present? 111 Yes Lil No
5. Observed cindition of component pumped:
7.
If yes, was it cleaned? El Yes El No
Stewarts Septic 58 So Kimball St Bradford Ma
Company
Location where contents were disposed:
-20-soj1IIstbradfordma
of Hauler
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
Date
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