HomeMy WebLinkAboutSeptic Pumping Slip - 107 GRANVILLE LANE 10/18/2017 C mm-onwealth of Massachusetts
RECOVED
City/Townof North Andover
4 ?,0 1
$ystern Pumping Record 7
F6rm 4 IC)WN Of�NC ATI-10DOVER
jjEA THFPARTMENT
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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 yoL
local Board of Health to determine the form they use. The System Pumping Record must be submitted tt
-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 //-N
use only the tab' - Gmnu/41
key to move your Addrets
cursor-do not
6
use the return
key. City/Town State Zip Code
2.* Stystern Owner:
tab
Name
Address(If different from location)
CftyfTown State Zip Code
Telephone Number
B. Pumping Record 7
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Cornponent- El Cesspool(s) nt ,-!§eptic Tank El Tight Tank 0 Grease Trap
El Other(describe):
4. Effluent Tee Filter present? El Yes [G-Ko If yes, was it cleaned? F1 Yes Ell10
5. Observed condition of component1bumped:
6. System mped B
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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