HomeMy WebLinkAboutSeptic Pumping Slip - 594 BOXFORD STREET 8/15/2017Commonwealth nfK� Massachusetts
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System Pumping
Record
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Form 4
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DEP has provided this form for use by |ooe| Boards of Health. Other forms may Wmsed, but the
information must besubstantially 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 310CyWR15.351.
A. U�����'U^�m U����K����^��K8 ' _ Facility Information
Important: When
filling out forms 1. System Location:
onthe computer,
use only the tab'
mey to move your Address
ovmo upnm "" North Andover
use the return
key. CityfTown
2. Svub*mDwner:
Address (if different from location)
State Zip Code
CityfTown State Zip Code
Telephone Number
B.Pu00p'ng Record
1. Date of Pumping
3. Component: El Cesspool(s) c"S-
eptic Tank 0 Tight Tank
[-1 Other (describe):
4. Effluent Tee Filter El Yes El No
5. Observed cpndition of component pumped:
mc
Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20so-m4-u bnadford ma
iV
_=_�_
Signature of Receiving Facility (or attach facility receipt)
[j Grease Trap
If yes, was it cleaned? F] Yes F1 No
Vehicle License Number
System Pumping Record - Page 1 of I