HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 11/16/2017 (2) V,
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icbrrfrif Wealth of Massachusetts
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City/Town of North Andover NORTH ANDOVER
5y I TOWN OF
Eystem Pumping Record 14EALTH DEPARTMENT
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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 Syste/m Pumping Record must be submitt(
-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-When
filling out forrns 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-, do not
use the return W Cityrrown state 4 Zip Code
key.
2:"841yetern Owner:
-F::"161 V JcA4
A Af Name'.-
Address(N different from location)
City(Town State Zip Code
Telephone Number
B. Purtiolng Record
1.- Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Corp onent� n Cesspool(s) El Septic Tank F1 Tight Tank ❑ Grease Traj
El Other(describe):
4. Effluent Tee Filter present? n Yes n No If yes, was it cleaned? n Yes F1 No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradf6rd ma
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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