HomeMy WebLinkAboutSeptic Pumping Slip - 252 BOXFORD STREET 1/16/2018 w a
Cam'M`a�wealth of Massachusefits
City/Town' of North Andover
Systern Pumping Record
,.` Form 4
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 submittec
-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 form§ . 1. System Location: �—
on the computer, ~LL
use only the tab
key to move your Address
cursor-do not
use the return
key, City/Town State Zip Code
"" 8�stem Owne
Name"
Address(if different from location)
City/Town State ip Cid
Telephone Number
B. Pumping Record
, 4ptic
1. Date of Pumping /Date Quantity Pumped: Gallons3. Comnponent: ElCesspool(s) Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Ye 194/0
o If yes, was it cleaned? ❑ Yes ❑ No
5. Observedndition component pumped:
6s m Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
1
7. Location where contents r 'sposed:
20 mill st bradfor ma —
Sig re of Hauler Date'
\ ignature of Receiving Facility(or attach facility receipt) Date
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