HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 8/15/2017Important: When
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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 cfHealth orother approving authority within 14days from the pumping date in
accordance with 310CyWR15.351.
A. Facility Information
26
Address
North Andover
City/Town
2. System Owner:
Address (if different frorn location)
City/Town
B'Pump.ng Record
1. Date of Pumping
3. Component: D (s)Fl Septic Tank D Tight Tank El Grease Trap
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State Zip Code
State Zip Code
Telephone Number
Other (describe):
-1 \/\-_[-1
Date-~--'~� ' —''~-:
4. Effluent Tee Filter present? D Yes E] No If yes, was it cleaned? L1 Yes El No
5. Observed opnddiunofcomponent pumped:
Pumped By:
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StevwadsSeptic 58SoKi boUSt8radfmrd Ma
Company
. Location where contents were disposed:
Omtmill ot bnadfnnd ma
ature of Hauler'
Receiving Facility (or attach facility receipt)
Vehicle License Number
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System Pumping Record - Page 1 of 1