HomeMy WebLinkAboutSeptic Pumping Slip - 520 FOSTER STREET 12/12/2017 10
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of Massachusetts
City/Tow' n' of North Andover
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ystem Pumping Record
i DEVIAMMENT
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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 yl
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,
_5
use only the tab (-�-o -F
key to move your Address
cursor-do not
use the return
key- Cityr;w; State Zip Code
2:"' Sllystem Owner:
-_=�
/h/l
Nam6,.,
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of PumpingDatGallons
2. Quantity Pumped: 1560
e
3. Com' ponent:' ❑ Cesspool(s) D'Septic Tank n Tight Tank F] Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? El Yes [I No If yes, was it cleaned? ❑ Yes El No
5. Observed condition of component pumpedA
.
6. System Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradf6rd ma
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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