HomeMy WebLinkAboutSeptic Pumping Slip - 203 GRANVILLE LANE 10/13/2017 r
Commonwealth of Massachusetts
RECEIVED
City/Town of north Andover i
17
System Pumping Record
.r Form 4.
TOWN r��i�RI'l�4,�NDOVER
HEAUP i F)AF°'I"MENT
<' DEP has provided this form for use by local Boards of Health. Other forms may be used, but the t
information must be substantially the same as that provided here. Before using this form, check with your 1
a: local Board of Health to determine the form they use. The System Pumping Record must be submitted to I
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 Address
cursor-da not
North Andover
use the return -- _..-.__.
key. Clty/Town State Zip Code
2. System Owner:
� � I
Name f
Address(if different from location)
City/Town State Zip Code
__.--------__._
Telephone Number
r,
B. Pumping Record
1. Date of Pumping 1Q� y p
Dat`e ( � 2. Quantit Pum ed: Gallos
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -
;w 4. Effluent Tee Filter present? ❑ Yes �,KNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Nanie Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signatdfe of Hader Date
t.
Signature of Receiving Facility(or attach facility receipt) Date
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