HomeMy WebLinkAboutSeptic Pumping Slip - 73 CHRISTIAN WAY 12/12/2017 ry
` omnnoiruealth of Massachusetts `P
,
City/ "own of North Andover
_ System Pumping Retard
M ♦`rL
Form 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 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
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 cityfrown State Zip Code
key.
2"' System Owner:
IL
r N•eme'.
Address(if different from location)
„
City/Town State � �� � p Co
Telephone Number
B. Pumping Record
1. Date of PumpingDate �Y antity Pumped: Gallons
3. Component.` ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): , 6$ 00
4. Effluent Tee Filter pres t? es El No If yes, was it cleaned? Y
5. Observed c clition of component pumped:
6. System P�r/o
-By: �(11_1;"a
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Br ford Ma
Company
7. Location where contents were disposed: l
20 so mill st bradfor a }
irk
Signat a of Hauler d'' Date
Si ure of Receiving Facility(or attach facility receipt) Date
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