HomeMy WebLinkAboutSeptic Pumping Slip - 39 DEER MEADOW ROAD 8/15/2017Important: 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 pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
CCA1LI) Oee
Address
City/Town
2, System Owner:
3
State Zip Code
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Component:
Date
LI Cesspool(s)
El Other (describe):
4. Effluent Tee Filter present? El Yes
5. Observed condition of compon t pumped:
or
State
Telephone Nurrfb
uantity Pumped:
Septic Tank El Tight Tank LJ Grease Trap
Zip Code
_/5'erD
Gallons
If yes, was it cleaned? I=1 Yes El No
6. Sysi�mPumped By:
./r_.2nef
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
21 so mill st srd ma
oa
ognature of Haul
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
Date
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