HomeMy WebLinkAboutSeptic Pumping Slip - 1 BRECKENRIDGE ROAD 9/11/2017 �
Commonwealth of Massachusetts
City/Town
'f /Tow[ 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
.Asim
the local Board of Health or other approving authority within 14 days from the pumpinc Otted to
accordance with 310 CIVIR 15351, WOW
A. Facility Information
Important:When ' �~
filling out forms 1. System Location:
onthe computer,
use only the tab
-t-T -kcfl-�t -4 - "I'll- ..........................
key tomove your *wunwv
cursor-do not
North Andover
"vothor�om �------- ------������
key. City/Town State Zip Code
2. System Owner:
-------
Address(if different from location)
o��p�� —— State — Zip Code -
-
TelowhonoNumhe,
B. Pumping Record
1. Date ofPumping Date2. Quantity Pumped: Gallons
3. Component: Fl Cesspool(s) [T~SepUoTonk El Tight Tank R Grease Trap
[] Other(describe): ----
4. Effluent Tee Filter present? Fl Yes F| No |fyes, was itcleaned? Fl Yea El No
-. ---_. - pumped:_\�
6. 8 a�
Na Vehicle License Number
warts Septic 58 So Kimball St Bradford Ma
ompany
7. Location where contents were disposed:
20 so mill st bradford ma
)Sign r�e-o�fa I e r D ate
nature of Receiving Facility(or attach facility receipt) D ate
t5/o,m*.uoc~11/12 System Pumping Record~Page 1vf1