HomeMy WebLinkAboutSeptic Pumping Slip - 429 WAVERLY ROAD 10/12/2017Important: When
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I' Pt
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:
(-tact ik.a\itt-((,
Address
North Andover
City/Town
2. System Owner:
\(-7
Name
Address (if different from location)
City/Town
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
Date of Pumping
3. Compopent:
Other (describe):
CI —
Date
Cesspool(s) 111
(7-7
4. Effluent Tee Filter present? 0 Yes
5. Observed condition of component pu y
2. Quantity Pumped:
Gallons
tic Tank 0 Tight Tank 0 Grease Trap
C
6. System Pu
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill_ t bradford
(77T
Sign
Signature of Receiving Facility (or attach facility receipt)
If yes, was it cleaned? 0 Yes CI No
Vehicle License Number
Date
Date
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