HomeMy WebLinkAboutSeptic Pumping Slip - 35 BOXFORD STREET 9/11/2017Important: W hen
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Commonwealth 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 mitted to
the local Board of Health or other approving authority within 14 days from the pum
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location: e,
Address
North Andover
City/Town
2. System Owner:
(IVO tk(
Name
Address (if different from location)
City/Town
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
S I Li
Date
LI Cesspool(s)
2. Quantity Pumped:
Gallons
0Septic Tank El Tight Tank II] Grease Trap
El Other (describe):
4. Effluent Tee Filter present? LI Yes
5. Observed condition of component pumped:
6. System Pumped By:
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill adford ma
Signet
e of Haul
Signature of Receiving Facility (or attach facility receipt)
If yes, was it cleaned? El Yes
Vehicle License Number
Date
Date
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