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HomeMy WebLinkAboutSeptic Pumping Slip - 320 BOXFORD STREET 9/11/2017Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 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 l5form4.doc• 11/12 System Pumping Record • Page 1 of 1