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HomeMy WebLinkAboutSeptic Pumping Slip - 467 SALEM STREET 2/7/2018 ©mim`'bl*ealth of Massachusetts City/Town of North Andover $ /stern 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 s local Board of Health to determine the form they use.The System Pumping Record must be submi#tet 9 •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:wfieci filling out forms .. 1. System Location: on the computer, use only the tab key to move your -Address cursor-do not' use the return key. City[raw � State Zip Code i 2: *stein Owner: Name' r Addrew,(if different from location) Cityfrown State Zip Code Tc,'ephonc Nurnbcr B. Pumping Record 1, Date of Pumping Date 2. Quantity Pumped: Galo 3. Component:' ❑ Cesspool(s) b'Septic Tank ❑ Tight Tank © Grease Trap © Other(describe): 4. Effluent Tee Filter present? Ej Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: C", r2 J 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 0 0- Signature Hauler Cate Signature of Receiving Facility(or attach facility receipt) [late t5form4.doc-11/12 System Pumping Record-Page 1 0