HomeMy WebLinkAboutSeptic Pumping Slip - 77 BRUIN HILL ROAD 10/16/2017 RECEIVED
0CCommonwealth of Massachusetts
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x ANDOVER
City/Town ofRTH
OWN OFDEPARTMENT
°
System Pumping Record NORTH ANDOVER
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 tilling out t. System Location:
forms on the r
computer,use _.�._[ ,r'c., . !......._ .._.V"G._.. ...,_._ ...._ _...____,.__ ....._.. .,_ .._ _..
onty the tab key address
to moveour
cursor-do not Cilyl i own �r tJ�
use the return State Zip Code
key.
2. System Owner:
VQ
Name
Address(i1 different from IocaSion)
City/Toovn State Zip Code
Tefephone Number
B. Pumping Record / /t
'I. Date of Pumping (�-� � - 2. Quantity Purnped: MOD
Date Gallons
3. Type of system: ❑ 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. Condition of System:
c;
6. System Pumped By:
Name vehicle License Number
Company e _. ._ ...._._.....__........ ..._
7. Location where contents were disposed:
40 S prte3
Signature of Hauler ~--_. .__.._. .. ®�4Sw.J�
. �.
_...
f 6 ftrd
__.___.____.__.____�.._....__._.___-__w,_,.._ .. _.._.., . .. ? . 'j'Aa_1-831
Signature of Receiving Facility Date
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