HomeMy WebLinkAboutSeptic Pumping Slip - 174 INGALLS STREET 1/16/2018 { 439
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-C.0 a'n`nrealth of Massachusetts
4. C ty/Tow' n" of North Andover
System 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 forms , 1. System Location:
an the computer,
use only the tab T^
key to move your Add res r
cursor-do not Crown /�.,� vtGf
use the return C, f 1
vo
key. �' State Zip Code
2:"' S�stern Owner.
A",
Name',
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date uantitYPumped' Gallons
;;>2.
pticT3, Components Cesspool(s) ank
❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes F1 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component,pumped: j
6. S stem,Pum d B : ,• '"
Y �.
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
2O.so rt'li st bradfor rFra j
' Signaru'r° of Nau � Date
= �
i
Signature of Receiving Facility(or attach facility receipt) Date
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