HomeMy WebLinkAboutSeptic Pumping Slip - 1005 FOREST STREET 11/16/2017 m I}4
/' A `� •
RECEIVED
n Nei
' Carr�alth of Massachusetts
Cl y/Town of North Andover 1 ,
System Pumping Record TOWN OFNOlmUH ANDOVER
F6rm 4 KAI..TH DE11ARTMENT
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
local Board of Health to determine the form they use.The System Pumping Record must be submitte
-the local Board of Health or other approving authority within 14 days from the pumping date in
accordanoe with 310 CMR 15.351.
A. Facility Information
Important:WheA
filling outfonns 1. System Location:
on the computer, "
use only the tab �Cr
key to move your Address
cursor-, do not
usethe retum Cityfrown state 4 Zip Code
key.
r�
2",S`yatem Owner:
Name'
Address(if different from location)
City/Town state Zap Code
Telephone Number
B. Pumping Record
1.-. Date of Pumping 2. Quantity Pumped: fk)
p g ty p Date Gallons
3. Component:' ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Grease Tra
(� Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped Bye
Name r� 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
Signature of Receiving Facility(or attach facility receipt) Date
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