HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 8/15/2017 (2)Important: 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:
Address
North Andover
City/Town
2. System Owner:
f
,vame
Address (if different from location)
City/Town
State
State
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component: Lil Cesspool(s) Lil Septic Tank El Tight Tank RGrease Trap
III Other (describe):
4. Effluent Tee Filter present? El Yes 111 No If yes, was it cleaned? 11 Yes 111 No
5. Observed co dition of component pumped:
2. Quantity Pumped:
Pumped By:
ame
Date
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
II st bradford ma
Si turd' of Hauler
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
Date
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