HomeMy WebLinkAboutSeptic Pumping Slip - 885 FOREST STREET 9/11/2017Important: Wheri
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6bmrribiiwealth 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
\(")
City/Town
2. S'stem Owner:
ff)
Name
State Zip Code
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date 2. Quantity Pumped:
3. Component: U Cesspool(s) IF —Septic Tank LI Tight Tank
LI Other (describe):
4. Effluent Tee Filter present? LI Yes Ir.No
5. Observed condition of component,,pumped:
CCCd
)
6.
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed;.. -
Signature of au
Signature of Receiving Facility (or attach facility receipt)
Gallo
LI Grease Trap
If yes, was it cleaned? D Yes Li No
Vehicle License Number
Date
t5form4.dcc• 11/12
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