HomeMy WebLinkAboutSeptic Pumping Slip - 245 OLD CART WAY 11/16/2017 RECEIVED
Commonwealth of Massachusetts kil�'JV 14 `?017
City/Town of North Andover .TOWN OF tjORTH ANDOVER
System Pumping Record l,.�F-Affii DEPAKrMENT
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 --d q S--- - ''-- - --- ----—, --- --
key to move your Address
cursor-do not North Andover
use the return
key. City/Town State Zip Code
2. System Owner:
tab
---- ..............
Name
stun
-;kddr—ess(�i"4�ffe— -
different
ocation)--- ... .............
........... .............
City/Town State Zip Code
Telephone-Number
B. Pumping Record
1. Date of Pumping pate te 2. Quantity Pumped: Gallons
3. Component: F] Cesspool(s) Septic Tank 0 Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? F] Yes 91NO If yes, was it cleaned? El Yes [:1 No
5. Observed condition of component pumped:
1�1 X- ClefW...5-1-
6. System Pumped By:
V\
Nam 4- Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
...................
��Ignaiurc/bf FTauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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