HomeMy WebLinkAboutSeptic Pumping Slip - 283 CAMPBELL ROAD 12/12/2017 Z.,
CbmTrIl'or)Wealth of Massachusetts
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City/Tow' n' of North Andoverw°„° °"' "
$,ystem Pumping Record
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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 YOL
local Board of Health to determine the form they use. The System Pumping Record must be submitted b
-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 AdWres;
cursor-do not
use the return
key. City/Town State Zip Code
2 A
8�stem Ow ner: 4
Name
Address(if different from location)
Cityfrown State Zip Code
Tebephone Number
B. Pumping Record
1. Date of Pumping Quantity Pumped:
D ate Gallons
3. Component*-- El Cesspool(s) Septic Tank El Tight Tank F] Grease Trap
El Other(describe):
4. Effluent Tee Filter present? 0 Ye4�0� If yes, was it cleaned? El Yes ❑ No
5. Observed conditian of coTponent pumped:
-7
6. sy u, ped BVI&
y, j�p-
A61
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so An ill st br6Cf0_R ma
Signa
re of H
�u---
Dae
! n�.re
of Receiving Facility(or attach facility receipt) Date
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