HomeMy WebLinkAboutSeptic Pumping Slip - 62 STONECLEAVE ROAD 9/11/2017Important: When
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Omn-for)i'mealth 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 pum•11#' date in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
City/Town
2. SI/stem Owner:
State
Zip Code
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 17- 2. Quantity Pumped: 0 Op
Date Gallons
3. Component: Cesspool(s) 14(eptic Tank ID Tight Tank [I] Grease Trap
El Other (describe):
4. Effluent Tee Filter present? 0 Yes ID -NO
5. Observed conj ition of component pumped:
00
6. System Pumped By:
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st br ford ma
Sig ureor a er
If yes, was it cleaned? E] Yes EJ No
Vehicle License Number
Signature of Receiving Facility (or attach facility receipt) Date
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