HomeMy WebLinkAboutSeptic Pumping Slip - 71 BEAVER BROOK ROAD 7/12/2017Important: When
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NUM
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
0„,, • 1'2_ (10\1
lows NORTH ANDOVER
HEALTH 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:
Vtr 6-6()
Addre
City/Town
2. System Owner:
State
Zip Code
Name
Address (if differen from location)
City/Town
State
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
3. Component: 111 Cesspool(s)
ID Other (describe):
4. Effluent Tee Filter present? III Yes
2. 9.pantity Pumped:
ISZYD
Gallons
Septic Tank El Tight Tank 11 Grease Trap
5. Observed condition of component pumped:
If yes, was it cleaned? LJ Yes Li No
6. Sy,stem-riTrriped By:
j /5/7kler
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so ill st bradford
Signat re of Hauler
Sigpture of Receiving Facility (or attach faciUty receipt)
Vehicle License Number
Date
Date
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