HomeMy WebLinkAboutSeptic Pumping Slip - 675 FOREST STREET 12/12/2017 ` orrm`a' iinrealth of Massachusetts J
Cityffown• of North Andover `
w System Pumping Record jMg0�J�lxi<lil�ii�
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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 y�
local Board of Health to determine the form they use. The System Pumping Record must be submitter
-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
key. Cityfrown State Zip Code
2.* System Owner:
Name'
earn
Address(if different from location)
Cityfrown State Zip Code
'telephone Number
B. Pumping Record
1. Date of PumpingDate 2. Quantity Pumped: Gallons
j.
3. Component' ❑ 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:
6. System Pumped By:
ell
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford "
si�nature "' Date
Signature of Receiving Facility(or attach facility receipt) Date
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