HomeMy WebLinkAboutSeptic Pumping Slip - 1048 GREAT POND ROAD 3/12/2018 uw
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Commonwealth of Massachusetts
City/Town of North Andover
° System Pumping Record
a 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 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, r
use only the tab `t
— ....................._ __... __..__...
key to move your Addre
cursor-do not , MA
use the return _ti.....—.-.-._._. _ —_.. ..._.. _..._.__._ ..
key. City/Town State Zip Code
2. System Owner:
rsb
Name — __. . ......_............_. _..._......_._._—.._
re2rn
Address(if different from location)
City/Town State' Zip Code
Telephone Number
B. Pumping Record
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1. Date of Pumping o — / 2. Quantity Pumped: aeons
3. Compon nt: ❑ Cesspools) ElSeptic Tank F-1Tight Tank ❑ Grease Trap
ther(describe): _........
4. Effluent Tee Filterresent?
p ❑ Yes Q,.,No If yes, was it cleaned? El Yes ❑ No
5. Observed condition of component pumped:
6. Sys Ym Pum ed By:
_-/ 4 1
Name Vehicle License Number
Stewart Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed: J
0
So. lit 111 St., Bradford, MA
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J�i6naure of Hauler Dat
Signature of Receiving Facility(or attach facility receipt) Date
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