HomeMy WebLinkAboutSeptic Pumping Slip - 288 FOSTER STREET 10/18/2017 �LN ' Commonwealth of Massachusetts
RECEIVED
City/Tow' n' of North Andover
$�ystem Pumping Record
•rom OF-NORT iA MD()VER
Form 4
KALTH F)EPARTMEW
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(
Ahe local Board of Health or other approving authority wit!-iin 14 days from the pumping date in
accordance With 310 CMR 15.351.
A. Facility Information
Important:When
filling out form§ . 1 System Location:
on the computer,
use only the tab Fk
key to move your Address
cursor-do not
use the return
key. CftyfFown State Zip Code
2 System Owner:
Cit (&t nc
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of PumpingDate Quantity Pumped:
GalloA
3. Com' ponent� ❑ Cesspool(s) Septic Tank n Tight Tank El Grease Trap
El Other(describe);
4. Effluent Tee Filter present? Ej Yes No If yes, was it cleaned? ❑ Yes El No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
71. Location where contents were posed:
p,
ZO ill st r
-agjjill st bradfor
A-7
C)
u
I re of Date
Signature of Receiving Facility(or attach facility receipt} Date
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