HomeMy WebLinkAboutSeptic Pumping Slip - 120 DUNCAN DRIVE 7/9/2018 Commonwealth � �f�,
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City/Town ��/ No. Andover, M
System Pumping Record PNumA'R
Form 4 �pEpkmv;KV
DEP has provided this form for use by |ooe| Boards of Health. Other forms may he used, but the
information must be substantially the name 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 |oom| Board of Health nrother 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(omove your *udmue
cursor-do not North Andover
MA 01945
uuethenetum —--------------
key. City/Town 0tote ZipCode
2. System Owner:
Neme
Address(if different from location)
City/Town State Zip Code
Telephone Number ---- �
B. Pumping Record
1. Date ofPumping Date2. Quantity Pumped:
3. Component: [l Cesspool(s) &-SepUcTanh F� Tight Tank R Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? [] Yes [] No If yes, vvr,j it cleaned? [T Yeo No
5. Observed condition of d
6. System Pumped r-
Nomo-- � VeNu|ouuenmeNumuor
Stewart's 8 tic 58 So. Kimball St., Bradford,MA
Company
7, Location where contents were disposed:
~
Signature of Date
Signature ofReceiving Facility(or attach facility receipt) oahy
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