HomeMy WebLinkAboutSeptic Pumping Slip - 240 RALEIGH TAVERN LANE 12/12/2017 � .., r� e q.
, omm';o;n"-Wealth of. Massachusetts l
Ib ty' Town of North Andover
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N �. �.��St nPumping Record rt�l�tt�
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DBP 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
local Board of Health to determine the form they use, The System Pumping Record must be submitte I
-the local Board of Health or other approving authority within 14 days from the pumping date in
accordanoe with 310 CMR 15.351.
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A. Facility Information
Importard:W herw
fitting out forms 1. System Location:
on the computer, /
use only the tab C' / / /G �✓
key to move your Address
cursor-,do not
use the return Cityrro—T-' `❑ State Zip Code
key.
r�
2:k System Owner:
Name`
> m Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
a
1.. . Date of PumpingD e 2. Quantity Pumped: Gallons` �
3_ Co mmponent� ❑ Cesspool(s) [tr Septic Tanis ❑ Tight Tank n Grease Tra,
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes M,No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
9 ( I
6. System Pumped
By:
Ndme Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
1,
7. Location Where Contents were disposed:
20 so mill st bra ord ma
L2
Sign re of H Date '
Signature of Receiving Facility(or attach facility receipt) Date
MWAMVIA AL .1111 D-A..Dann