HomeMy WebLinkAboutSeptic Pumping Slip - 205 CAMPBELL ROAD 10/12/2017 IR
s ;
Commonwealth of Massachusetts a W
City/Town of North Andover
System Pumping Recordwc � ' �
Form 4.
i
>x 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 t
local Board of Health to determine the form they use. The System Pumping Record must be submitted to i
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
Important:when
filling out forms 1.N> System Location:
on the computer, �`
use only the tab
key to move your Address
cursor-do not North Andover
use the return City/Town State Zip Code
key.
X1'1
System Owner:
VII ( (,7- (( "
ll `f ,
Name _
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of PumpingDate ( — 2. Quantity Pumped: Gallons— .
3. Component: Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
%. 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observedndition of component pumped:
r S'n1'Pumped<By:
:rts
am,eer Vehicle License Number
waSe tic 58 So Kimball St Bradford Ma
company
7. Location where contents were disposed:
ill st Bradford ma
Jign t of Hauler Date
pature of Receiving Facility(or attach facility receipt) Date
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