HomeMy WebLinkAboutSeptic Pumping Slip - 55 FARNUM STREET 7/12/2017Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
JU1 Z017
Too OF NoRTHANDPVER
TH DEPARTMENT
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
1. System Location:
)—( 0Lt C(1
Address
North Andover
City/Town State Zip Code
2. System Owner:
c \-(1Name
--c(ca.
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
16 )
2. Quantity Pumped:
3. Component: LI Cesspool(s) ,"Septic Tank
LI Other (describe):
4. .Effluent Tee Filter present? El Yes 2/No
5. 0bserved1condition pf component pumped:
VA
6. System Pum
Name
Stewarts ep To-58 So Kimball St Bradford Ma
Company
ID Tight Tank 11111 Grease Trap
If yes, was it cleaned? El Yes LIJ No
7. Location where contents were disposed:
20 so mill st bradford ma
Vehicle License Number
Signature of Hauler
Signature of Receiving Facility (or attach facility
Date
ceipt) Date
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