HomeMy WebLinkAboutSeptic Pumping Slip - 31 OXBOW CIRCLE 11/16/2017 FRZECEIVED
_C_\ C Orri;a&iiwealth 'of Massachusetts
city/Town of North Andover
System Pumping Record T()W�j of�lqo�U'H At4r.)OVER
F6rm 4 H[-ALVl4 0VARIME11T
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 ti
-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 31 OX &Wn' r-
key to move your Address
cursor-do not
use the return
key. CKytrown State Zip Code
2 SWern Owner:
Name'.,
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D ate Gallons
Z. Quantity Pumped: C")
3. Com' ponent~ ❑ Cesspool(s) [9-S—eptic Tank El Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? El Yes &_-No If yes, was it cleaned? r] Yes Ej No
5. Observed condition of com7nent pumped:
6. System Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where conte*<er�Jsp6sed:
2Q-po mill stradf5/d ma,,,/,
Signaturelof'14�e
Date
Signature of Receiving Facility(or attach facility receipt) Date
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