HomeMy WebLinkAboutSeptic Pumping Slip - 1935 SALEM STREET 7/9/2018 Commonwealth of Massachusetts
City/Town of No. Andover, MA Irk
Form
Syst4 em Pumping Record
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114 or.@JOR
DEP has provided this form for use by local Boards of Health. Other forms r❑ tt
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,
o
use only the tab tt
........... ................ ........................................
key to move your Address
cursor-do not North Andover MA 01945
use the return
key. City/Town State Zip Code
2. System Owner:
rab
L� Etc
Name
reMn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping f r 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) F-1 Septic Tank Ej Tight Tank F-1 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? F-1 Yes eo If yes, was it cleaned? F-1 Yes E—tq-010'
5. Observed condition of component pumped-
..........
6. System Pum 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. r, ord, MA
..........................
Signature of r
Date
Signature of Receiving Facility(or attach facility receipt) Date
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