HomeMy WebLinkAboutSeptic Pumping Slip - 127 ABBOTT STREET 10/12/2017 Commonwealth of Massachusetts 11',�I
City/Town of North Andover
-
U.' 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
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 12?
key to move your Address
cursor-do not North Andover
use the return
key. CityfTown State Zip Code
2. System Owner:
tab
-Narn 11 e
rerun
--- --------------- .......
Address(if different from location)
...........
CityfTown State Zip Code
-Telephone Number
...........
B. Pumping Record
1 Date of Pumping 1 -2
2. Quantity Pumped:
Date Gallons
3. Component: El Cesspool(s) EySeptic Tank n Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? El Yes R No If yes, was it cleaned? 0 Yes El No
5. Observed condition of component pumper'
CA
................
6. System Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
-6-0m'pany---Septic
Location where contents were disposed:
20 so mill st bradford ma
.............. ...............
Signature of-Hauler-- ----------- Date
Signature of Receiving Facility(or attach facility receipt) Date
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