HomeMy WebLinkAboutSeptic Pumping Slip - 300 DALE STREET 10/12/2017Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
70
0,\
foor
la,o 010.
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:
6,t) bcd-cS.
Address
North Andover
Cityffown
2. System Qwner:.
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
Date
State Zip Code
().
State Zip Code
Telephone Number
2.Quantity Pumped:
Gallons -
3. Component: Elil Cesspool(s) Septic Tank III Tight Tank 111 Grease Trap
111 Other (describe):
4. Effluent Tee Filter present? LI Yes Ilfr—Rlo
5. Observed condition of component p ed:
6. System Pumpe :
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
I st bradf
If yes, was it cleaned? 111 Yes 111 No
Vehicle License Number
Signature of Receiving Facility (or attach facility receipt) Date
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