HomeMy WebLinkAboutSeptic Pumping Slip - 303 BERRY STREET 11/16/2017 - FF3..„��¢ r� y
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C.6- ,mau'nr'rvealth of Massachusetts
City/Town of North Andover
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$ystem Pumping Record
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Form 4
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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 y(
local Board of Health to determine the form they use.The System Pumping Record must be submitted
•the local Board of Health or other approving authority within 14 days from the pumping date in 1
accordance with 310 CMR 15.351.
A. Facility Information
important:when
filling out forms . 1. System Location: e—
on the computer, ' ! L1'
use only the tab (30
key to move your Address
cursor-do not
use the return City/Town State Zip Code
Y
2.* *,sAe wner:
Name :
ream
Address(if different from location)
Cityrrown State Zip Cede `
Telephone Number
B. Pumping Record
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1. Date of Pumping ! Quanti Pumped:
ed: t
p g Date Gallons
3. Components ❑ Cesspool(s) R'Septic Tank ❑ Tight Tank Grease Trap
El other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System P d B r `
y v:
Al 5
Name Vehicle License Number
Stewarts Septic 58 So Kimball St B, ford Ma
Company
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7. Location where contents were disposed:
20 sQ mill st br4dfor4pa
Sign re of Haulercww, Date J
m nature of Receiving Facility(or attach facility receipt) Date
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