HomeMy WebLinkAboutSeptic Pumping Slip - 2225 TURNPIKE STREET 5/7/2018 RECEIVED
Commonwealth of Massachusetts
MAY
City/Town of North Andover
TOWN ONOTVER
System Pumping Record F, RH ANDO
t4EALTH DS'IAMWEN r
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, e L - -'5 '---
use only the tab 0'a 1 —9—
.............. ........... ........................................................
key to move your Address
cursor-do not NO MA
use the return
key. City/Town State Zip Code
2. System Owner:
rsb
Name
---------------------------....................................... . ..............
Address(if different from location)
......................
City/Town State Zip Code
Telephone Number
B. Pumping Record L11LI/ ��r -
1. Date of Pumping Date - 2. Quantity Pumped: Gallons :4?.........................................
-
1 Component: El Cesspool(s) 4 Zeptic Tank ❑ Tight Tank ❑ Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? F-1 Yes n No If yes, was it cleaned? Fj Yes Ej No
5. Observed condition of component pumped:
6. Sys Pumpy:
kAllo '71;rdA�....— ---- -- - --
Ngme ' Vehicle License Number
'.Stew'art�aPptic 58 So. Kimball St., Bradford,MA
..........
Company
7. Location where contents were disposed:
Q20 So. �-Il S4, Bradford., MA-
ig7)ture of Haabfer
Signature of Receiving Facility(or attach facility receipt) Date
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