HomeMy WebLinkAboutSeptic Pumping Slip - 79 BEAVER BROOK ROAD 11/16/2017 RECEIVED
Commonwealth of Massachusetts
A City/Town of North Andover �tl` 141
"a. System Pumping Record TOWN OF NRTHANDOVE.
wHEALTH DEPA�°t�' ENT
Farrra 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 l
accordance with 310 CMR 15.351.
A. Facility Intarrmatian
Important:When
filling out forms 1. System Location:
on the computer, ` /
V
e /�,�"`�,
use only the tab V (� I`
key to move your Address
cursor-do not North Andover
use the return --— - ----------------- _._...
key. Cityfrown State Zip Code
2. Sy m O ner: �
Name - ----------
rerun
Address(if different from location)
i
City/Town State Zip Code
Telephone Number
B. Pumping Retard
1. Date of Pumping Da� -- 2. Quantity Pumped: Lallans
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): )
4. Effluent Tee Filter present? ❑ Yes Iivo� If yes, was it cleaned? ❑ Yes ❑ No
i'
5. Observed condition of companent pumped:
6. System Pu ed By: f
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 I st bradford rn
Signa o ler Date
Signature of Receiving Facility(or attach facility receipt) Date
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