HomeMy WebLinkAboutSeptic Pumping Slip - 45 BANNAN DRIVE 7/9/2018 /
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vSystem Pumping Record H ~ uOBpR3NE1 `
Form 4
DEP has provided this form for use bvlocal Boards ofHealth. Other forms may beused, but the
information must b*substantially the same as that provided here, Before using this form, check with your
|ncm| Board ofHealth(odetermine the form they use. The System Pumping Record must besubmitted to
the local Board of Health orother approving authority within 14 days from the pumping date in
accordance with 31OCPNR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
onthe computer,
use only the tab
key tomove your Address
cursor-do not
North Andover PWA 01945
use the return
key. City[Town Qtynown State Zip Code
2. System Owner:
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
/
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1 Date - 2 C)u�nt�v Pumped:
� o�n � ~ � Gallons
1 Component cnespoo|(s) 0-94ticTonk El Tight Tank Grease Trap
[1
Other(describe):
4� Effluent Tee Filter present? F-1 Yeo Fl No |fyes, was dcleaned? [l Yen F-1 No
5. Observed condition of componentpumped:
6 System Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball 8t., Bradford,MA
Company
7. Location where contents were disposed:
20 So. K8U| St. Bradford, MA
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Signature ofHauler Date
Signature o[Receiving Facility(or attach facility receipt) Date