HomeMy WebLinkAboutSeptic Pumping Slip - 141 CARLTON LANE 9/11/2017Important: W heri
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ComrrionWealth of Massachusetts
City/Town of North Andover
System Pumping Record
Fcirm 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:
kT
Addre
City/Town
State
Zip Code
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
3. Component: 0 Cesspool(s)
0 Other (describe):
2. Quantity Pumped:
Septic Tanl 0 Tight Tank 0 Grease Trap
(tatPC,fri'-
tk:
4.
Effluent Tee Filter present? 0 Yes zr No If yes, was it cleaned? 0 Yes 0 No
5. Observed condition pf component punti ed:
6. Sy umped By:
Stewarts Se;tic5ETSa.Ximball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Vehicle License Number
Signature of Hauler
Signature of Receiving Facility (or attach facility receipt)
Date
Date
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