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HomeMy WebLinkAboutSeptic Pumping Slip - 124 TUCKER FARM ROAD 1/16/2018 i; .. 3� ,•:, Corr Onwealth of Massachusetts City/To vim' of North Andover -.. S,ystem 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 y4 local Board of Health to determine the form they use. The System Pumping Record must be submitted -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, _. use only the tab s 'l ? fa key to move your Address I f s cursor-do not use the return ITo C" key. �' State Zip Code 4�� '2 System owner: Name', Address(if different from location) Cityrrown State Zip Code i"Jephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. C©mponent� ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes El No If yes, was it cleaned? ❑ Yes El No 5. Observed condition of component pumped: 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 bradford ma Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date --------------- t5form4.doc•11/12 System Pumping Record•Page 1 of