HomeMy WebLinkAboutSeptic Pumping Slip - 59 WILLOW RIDGE ROAD 10/18/2017 ' C mrrio'nWealth of Massachusetts
RECEIVED
City/Tow' n' of North Andover N It")V 1 11 ?0 1 1
.0 $�ystem Pumping Record TOWN OF W)RI'H ANDOVER
Form 4
i,jE-A( Tit DERARTMENT
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 t(
-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, to
use only the tab °57 all-Ild6t,) A (
key to move your Address
cursor-do not
use the return
key. Cityrro_wn State Zip Code
40---h 2.* Slistern Owner:
k�biasao
Name
Address(If different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 uantity Pumped: uailons
3. Component.,' F-1 Cesspool(s) Tank Septic otic T� El Tight Tank El Grease Trap
Other(describe):
4. Effluent Tee Filter present? Ej Yes t-90--_ If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System
Pum By: o
E z
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were dispo'-s e
Oso RRN bradford
Signature of Herul&-- Date
Signature of Receiving Facility(or attach facility receipt) Date
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