HomeMy WebLinkAboutSeptic Pumping Slip - 284 BRADFORD STREET 10/12/2017Important: When
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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 Lo ation:
Ad r ss
North Andover
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
State
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping
3. Component:
Ell Cesspool(s)
111 Other (describe):
4. Effluent Tee Filter present? LI Yes
5. Observed condition of component pu
6. System P
Name
Stewarts‘ ep
d By: '
.V/10
2. Quantity Pumped:
Septic Tank E] Tight Tank
Gallons
1] Grease Trap
No If yes, was it cleaned? LI Yes 111 o
ped:
58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill dford ma
Sgraturo of Hauler
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
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