HomeMy WebLinkAboutSeptic Pumping Slip - 81 LACONIA CIRCLE 12/12/2017 dorr �alth of Massachusetts
City/Tow' n' of North Andover sp,�
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. ! yste rr P e�r�p�i r�g Record �Om o 1w�������i�� �������.��
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 yoL
local Board of Health to determine the form they use. The System Pumping Record must be submitted ti J
-the local Board of Health or other approving authority within 14 days from the pumping date in r
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
use the return C"
key "tYfrown
State Zip Code
2.2' System Owner: 4
G'
se-
Name
�anrn
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping record
1. Date of Pumping Date 2, Quantity Pumped:
Gallo6s
3. Component: Cesspool(s) ['Septic Tank El Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
C..
6. System Pumped By: r w
6 1
ar
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents wer�disposed: j
20 so mill st bradford m
y
Signature of aulet Date ( ( 1!
Signature of Receiving Facility(or attach facility receipt) Date
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