HomeMy WebLinkAboutSeptic Pumping Slip - 23 WILLOW RIDGE ROAD 11/16/2017 ' COMM'pimealth of Massachusetts RECEAVED
City/Tow' n' of North Andover
$.ystem Pumping Record
Farm 4 TOWN OF.NOVI ANDi.VER
4JEALTI-i DEPARTMENT
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 you
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,
use only the tab
key to move your Address
cursor-do not
usethe return
key. Cityfrown State Zip Code
ray
2."bk 8stem Owner:
Name
ream ,
Address(if different from location)
CityfTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping2. Quantity Pumped:
Date Gallons
3. Component, ❑ Cesspool(s) E�rSeptic Tank El Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? ❑ Yes E��No If yes, was it cleaned? El Yes El No
5. Observed condition of component pumped:
6. System Pumped B
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so ill St radford ma
Si nature aul_er Date
Signature of Receiving Facility(or attach facility receipt) b-a-te
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