HomeMy WebLinkAboutSeptic Pumping Slip - 235 OLD CART WAY 12/12/2017 m w w 4 K 4V '
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C 'MMOT)Vveaith of Massachusetts ,w
City/To w* n' of North Andover
._ S,ystem Pumping Recon!
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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 yi t
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
Location:
on the computer,
filling out form§ . System
use
the
ab
key mt your our Address
Y
cursor-do not
use the return ' /town
key. Ry State Zip Code
"2:* System Owner:
r� /
Name
� � kf l t
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Componeht:� ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Grease Trap
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
i
1
6. System Pumped By: t
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
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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