HomeMy WebLinkAboutSeptic Pumping Slip - 320 BOXFORD STREET 9/11/2017Important: When
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1. Date of Pumping
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 b bmitted to
the local Board of Health or other approving authority within 14 days from the pu
accordance with 310 CMR 15.351,
A. Facility Information
1. System Location:
3 a() TiV-Vic
Address
North Andover
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
-n
Date 2. Quantity Pumped:
3. Component: LI Cesspool(s)
El Other (describe):
4. Effluent Tee Filter present? E] Yes ErNo
5. Observed conditiorp
- etIV
6. Syst
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
ponent pumped:
Septic Tank
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler
Signature of Receiving Facility (or attach facility receipt)
alto
111 Tight Tank El Grease Trap
If yes, was it cleaned? LI Yes 111 No
Vehicle License Number
Date
Date
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