HomeMy WebLinkAboutSeptic Pumping Slip - 1100 SALEM STREET 9/11/2017Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pu ping 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
PC\
North Andover
City/Town
2. System wner:
1\1
Name
. _
Address (if different from location)
City/Town
State
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping R- I -) 2. Quantity Pumped:
Date Gallons
3. Component: Cesspool(s) Septic Tank 111 Tight Tank 0 Grease Trap
D Other (describe):
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? 0 Yes
5. Observed condition of component pumped:
6. System P ped By:
Name
Stewarts Septic58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
Vehicle License N(Ilber
Signature of Hauler Date
Signature of Receiving Facility (or attach facility receipt)
Date
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