HomeMy WebLinkAboutSeptic Pumping Slip - 197 BRIDGES LANE 12/12/2017 ( ominn'a'nv eaifih of Massachusetts s
City/Town' of North Andover
i
.. . .
�. S�ysten� Pumping Record
Farm 4 ��, �, a° t
1o'NNI G
DEP has provided this form for use by local Boards of Health. Oth4rl�ms may be used, but the
information must be substantially the same as that provided here:'Before using this form,check with
local Board of Health to determine the form they use. The System Pumping Record must be submitt(
-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
henlalling out farms .1. System Location:
on the computer, iy /
use only the tab ��-..JJ
key to move your Address
cursor-do not
usetheretum A City/Town State A Zap Code
k'eJy.
Qk
2,* Oyste Owner:
-� Name`s
ten, Address(if different from location)
City/r'own State Zip Code
Telephone Number
B. Pumping Record
1—. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component:' ❑ Cesspool(s) ( -b ptic Tank ❑ Tight Tank ❑ Grease Tra
❑ Other(describe): �,, "
4. Effluent Tee Filter present? El Yes L No If yes, was it cleaned? ❑ Yes No
5. Observed condition of fcompone t pumped:
6. S e Pu ped By:
C r lyI C.
Name vehicle License Number t
Stewarts septic 58 So Kimball St Bradford Ma t
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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