HomeMy WebLinkAboutSeptic Pumping Slip - 66 BOXFORD STREET 1/16/2018 CWTIM T*ealth of Massachusetts
u: Cityffow' n' of North Andover
.ystem Pumping Record
Form 4
4
DEP has provided this form for use by local Boar
ds 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 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 fom•rs 1, System Location:
on the computer,
use only the tab
key to move your Addres
cursor-do not
use the return ft� Rown
key. y State Zip Code
Oystem Owner:
�I
Name'••
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping /` 2. Quantity Pumped:
DateGallons
3. Componeht° ❑ Cesspool(s) [3'y
Tank F-1TightTank El Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Y No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi n of component pumped:
6, S em Pdmped By.
\Jylf
ame Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
0 so mill st brad ard- a
S gnature of Hauler ."
Dake
w�
Signature of Receiving Facility(or attach acility receipt) Date
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