HomeMy WebLinkAboutSeptic Pumping Slip - 64 BOSTON STREET 8/15/2017 ve
Comailunwealth of Massachusetts
City/Tow' n of North Andover
SYStern Pumping Record
Form 4 jo'gg0\A'De?N Cts
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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:Wheri
filling out forms . 1. System Location, 9
on the computer,
use only the tab
keY to move your Address
-do no
cursor
use the returnt 4CitfT
key. own N, State 7 Zip Code
00---h 2. S`ystem Owner:
(77,
Name
amen
Address(if different from location)
City/Town State Zip Code
Telephone
olephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) A Septic Tank R Tight Tank El Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? F] Yes [D No If yes, was it cleaned? El Yes Ej No
5. Observed condition of component pumped:
............
6. S�'ntem Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Sig Aatu're Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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