HomeMy WebLinkAboutSeptic Pumping Slip - 137 HAY MEADOW ROAD 11/16/2017 lcbnirrr inrealthbf Massachusetts RECEIVED'
City/Tow' n' of North Andover
$�ystem Pumping Record TOWN OF NORTH ANDOVER
F6rm 4 HEAUH 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 yoL
local Board of Health to determine the form they use. The System Pumping Record must be submitted tl
-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
key to move your Ad res
cursor-do not
use
e the return
key. cfty/tow&— State Zip Code
2.'4' S`ystem Owner:
aff
Name
raom
Address(K different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date 0 Gallon's
3. Component.-- ❑ Cesspool(s) [t,18eptic Tank Ej Tight Tank El Grease Trap
Ej Other(describe):
4, Effluent Tee Filter present? n Yes 01,,No If yes, was it cleaned? ❑ Yes El No
5. Observed condition of component pumped:
6. Sy�sem Pumped By:
NamVehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradf6rd ma
10
;Signat Weaf Ha r Date
Signature of Receiving Facility(or attach facility receipt) Date
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