HomeMy WebLinkAboutSeptic Pumping Slip - 259 CAMPBELL ROAD 7/12/2017Important: When
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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 • 1,0. Z /date in
accordance with 310 CMR 15.351. G
A. Facility Information
System Location:
Camp,x11A.
tr5 fi-c\
City/Town
2. System Owner:
vl.,. Name
Address (if different from location)
City/Town
,0\
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
Date
111 Cesspool(s)
2. Quantity Pumped:
El/Septic Tank III Tight Tank
LI Other (describe):
4. Effluent Tee Filter present? Ell Yes Erlo
5. Observed condition of component pumped:
1-0
6. System Pumped By:
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so ill st radford ma
Igo
Galions
LI Grease Trap
If yes, was it cleaned? Ell Yes D No
Vehicle License Number
Signature of Receiving Facility (or attach facility receipt) Date
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