HomeMy WebLinkAboutSeptic Pumping Slip - 466 WINTER STREET 12/12/2017 ' Corri°`�Wealth ofMassachusetts
City/Town of North ,Andover
ystem Pumping Record
Form 4 ���
DEP has provided this form for use by local Boards of Heal,n. Other forms may be used, but the
information must be substantially the same as that provides here `Before using this form, check with
local Board of Health to determine the form they use. The System Pumping Record must be submittE
-the local Board of Health or other approving authority within 14`days from the pumping date in
accordance with 310 CMR 15.351. I
A. Facility Information
Important:Wheq
fii6ng out fom s 1. System Location:
on the ,com uter
p �use only the tab Ccs ld�°/ 6'r d 7
key to move your Address
cursor-,do not
use the return City/Town Stake A Zip Code
key.
2:"' S`(st(;m Owner:
Name'
rte, r Address(if different from location)
Cityfrnvm St Ie Zip Code
Telephone Number
B. Pumping Record e c�(j
1. . Date of.' hate Pumping 2-Quantity Pumped: Gallons —=)
.-�
3. Ccmponent: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Tral
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of cc cent pumped:
6. System ed By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
2p so mill st bradford ma
Sign " 0i of Ha"
a Date
Signature of Receiving Facility(or attach facility receipt) Date
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