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HomeMy WebLinkAboutSeptic Pumping Slip - 137 HAY MEADOW ROAD 11/16/2017 (2) w ry 4114. do,ff 6,,6r Wealth of Massachusetts RECEIVED v Uty/Town• of North Andover System Pumping Record Form 4 TOWN OF is R iii OIDOVER JJEAJ 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 System Pumping Record must be submittE -the local Board of Health or other approving authority within 14days;�ays from the pumping date in accordanoe with 310 CMR 15.351. A. Facility Information Important:when filling out forms .1. System Location: on the computer, use only the tab s ` ( key to move your Address cursor-, do not use the return City/Town state 4 Zip Code key. —�1 2*5°ystem Owner: _ Name`: Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of PumpingDate 2. Quantity Pumped: Gallons ) 3. Components ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trak ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped ay " Name Vehicle License Number Stewa 'Septic 58 So Kimball St Bradford Ma Company 7. Location where contents were disposed, 20 so mill st bradford ma Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date 4/•.fnrmd rirv.11!17 a„�.,..,C)„n•. ;i ©—..M.ED—