HomeMy WebLinkAboutSeptic Pumping Slip - 379 BOXFORD STREET 11/16/2017 RECEIVED
Commonwealth of Massachusetts
M City/Town of North Andover �q(' '14
a . System Pumping Record TOWCj OFNOR•i-iANDOVER
Y Form 4 h AL i-1 DEPARTMENT
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 lnfbrmation
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab _ " 3 f
key to move your Address
cursor-do not North Andover
use the return - --— --
key. Cityfrown State Zip Code
2. System Owner:
�A
Name
ietrm
Address(if different from Vocation)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ) 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. Observed condition of component pu d: j
-'r 6. System Pumpe By:
Name vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler Date
i
Signature of Receiving Facility(or attach facility receipt) Date
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