HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 2/7/2018 oirrop'iwealth of Massachusetts
pig Ci y/Town' of North Andover
System Pumping Record
Formry
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 submitte(
aAhe local
rd of 30 Health or other 15 35gapproving authority within 14 days from the pumping date in
cordance
o
A. Facility Information
Important.when
filling out forms ., 1. System Location:
on the computer, ,.
use only the tab
key to move your Address
cursor-do not'
key the return Cityrrown - state Zip Code
2:"1 SSrstem Owner:
SPC ice
Name':
Address(if different from location)
Cityfrown state Zip Code
Telephone Number
B. Pumping record
1. Date of PumpingDate l - 2. Quantity Pumped:
Gallons
3. Component:` ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ® Yes ❑ 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
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