HomeMy WebLinkAboutSeptic Pumping Slip - 1077 OSGOOD STREET 8/15/2017 Cbmrri of Massachusetts
City/Tow' n' oaf North Andover
wi System Pumping Record f
F6rm 4
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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
Important:When
filling out forms , 1 System Location:
on the computer,
use only the tab 1.0 -' �) os000d 4-
key to move your Adfjs �j
cursor- et not
use the return -
key. Cityrrown State Zip Code
41--�
2. S'�stem Qwnqr:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped:
Gallons
3. Component: E1 Cesspool(s) R Septic Tank [I Tight Tank EA—erease Trap
El Other(describe):
4. Effluent Tee Filter present? F-1 Yes ErNo If yes, was it cleaned? E] Yes El No
5. Observed condition of component pumped:
6. System u ed By:
Name Vehicle License Number
Stewarts Set) ic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler Date
Signature
ign,ture of Rec ng Facility(or attach facility receipt) Date
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