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HomeMy WebLinkAboutSeptic Pumping Slip - 565 OSGOOD STREET 3/12/2018 Commonwealth of Massachusetts City/Town of North Andover "y r x �b System Pumping Record Form 4 ❑ , w t<� DEP has provided this form for use by local Boards of Health, Other forms may IJI used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use, The System Pumping Record must be submitted to 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 14 R )2y/1 o r_. key to move your Address - � cursor-do not MA use the return Cit/Town key. y State Zip Code 2, System Owner: r� _r 1 rc-�--,o Pr-ed, ,/ Name rerun . Address(if different from Iocation) - City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping -Date 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 compo ent pumped: 6. System Pumped By: Name Vehicle License Number Stewart"s Septic 58 So. Kimball St„ Bradford,MA Company 7. Location where contents were disposed: 20 So. Mill St., Bradford, MA r Signature of Hauler Date Signature of Recelving Facility(or attach facility receipt) Date t5form4,doc•11112 System Pumping Record-Page 1 of 1,