HomeMy WebLinkAboutSeptic Pumping Slip - 149 SUMMER STREET 1/16/2018 r
• .Corrie oyiWealth of Massachusetts
City/Tawn' of North Andover
$ystem Pumping Record
Farm 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 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, G
use only the tab
key to move your Address
cursor-do not
use the return C' /town
key. ity State Zip Code
2.`System Owner: k.
Name`
Address(if different from location)
City/rown St
Telephone Number
B. Pumping Record .�
1. Date of Pumping
DateQuantity Pumped:
Gallons
3. Component~ ❑ Cesspools) ❑ ptic Tank ❑ Tight Tank F-1GreaseTrap
❑ Other(describe):
4. Effluent Tee Filter present? [IY� o if yes, was it cleaned? ❑ Yes 0 No
5. Observed condition of wnpo ent umped•-
6yst m Pum ed By:
f
arne _-- Vehicle License Number
Stewarts Se is 58 So Kimball St radford Ma
Company ti
7. cation wt I I is fir re dispos d:
0 so mill St pradford
Signature of Hauler Date
Signature of R iving Facility(or attach facility receipt) Date
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