HomeMy WebLinkAboutSeptic Pumping Slip - 32 BRIDGES LANE 8/15/2017Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
10 0
DEP has provided this form for use by local Boards of Health. Other forms may e 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
System Location:
tciL (IA
Address
City/Town
2. System Owner:
Name
State Zip Code
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
Date
State , , , jZio Cod
Telephone Number
2 eantity Pumped:
/6-61b
Gallons
3. Component: LI Cesspool(s) Septic Tank [11 Tight Tank El Grease Trap
D Other (describe):
4. Effluent Tee Filter present? LI Yes No
5. Observed con tion of pomponent pumped:
If yes, was it cleaned? El Yes LJ No
6. Sysfprfrju m pe5i-By.
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
Z.Nel.: Ofr-•---__
7. Location where contents were disposed:
0 so mill st bra46rd ma
Si.nature of Hauler
of Receiving Facility (or attach facility receipt)
2
--
Vehicle License Number
Date
Date
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