HomeMy WebLinkAboutSeptic Pumping Slip - 166 GRANVILLE LANE 12/12/2017 Y
Comrripl wealth of Massachusetts
City/Tow' n' of North Andover
4 System, Pumping Record
Farm 4
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 yot,
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 farms . 1. System Location:
on the computer, -/�
I 0 I����
use only the tab
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2 S'qstem Owner:
ff l l ll
Name
ratan ,.
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
❑ 2
C)Quantity Pumped: — )
1. Date of Pumping Date , ed: Gall n--��`s—
3. Component:' ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes n No If yes, was it cleaned? ❑ Yes ❑ No
.. ...yI
5. Observed condition of component pumped:
7(
6. System Pumped By:
D �
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
( su
i"
st bradford 7 t
signature H tale pate
Signature of Receiving Facility(or attach facility receipt) Date
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