HomeMy WebLinkAboutSeptic Pumping Slip - 127 TUCKER FARM ROAD 9/11/2017Important: When
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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 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:
\ 1 UCY-Cr
Address
North Andover
City/Town
2. System Own r: t
,
a
(ca\luchc
Address (if different from location)
City/Town
t
State
State
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping
3. Component: [1] Cesspool(s) EI Septic Tank [1] Tight Tank 111 Grease Trap
11:1 Other (describe):
4. Effluent Tee Filter present? Li Yes ENo If yes, was it cleaned? LI Yes El No
Date
5. Observed condition of compon nt pumped:
Quantity Pumped:
6. prf1Pumped y9 /
firerc 1 C.Cddi
N ame
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signa ure of Hauler
2.50 ure of Receiving Facility (or at(ach facility receipt)
4,
)
Vehicle License Number
Date
Date
t (5-0
Gallons
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