HomeMy WebLinkAboutSeptic Pumping Slip - 1607 SALEM STREET 7/9/2018 .... Massachusetts RECEIVED... _..
wCity/Town of No. Andover MA Ja. 1- w. 9 018
System Pumping Record "TOWN OF 0,Z11-1 I V R
Form 4 [L'AL111 DEVIA[[1TMEN°
Y L a
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
only the tab
othe computer, 1. System Locationa
key to move your Address
cursor-do not North Andover MA 01945
use the return .. .
key. City/Town State Zip Code
2. System Owner:
Name
rennn
Address(if different from location)'
City/Town State Zip Code
Telephone Number
B. Dumping Record .
1. Date of Pumping oa a 2. Quantity Pumped:
Gallons
3. Component: ❑ Cessp ol(s) [ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed congitiion of component pumped:
6. System,P.mped.By: ,
_. ._. _. �. ...... ........
Name Vehicle License Number
Stewart's Septic 58 So Kimball St., BradfordMA
Company
7. Location where contents were disposed:
20 So IISt Bradfo dJIA .....
Signature of cuter tate
Signature of Receiving Facility(or attach facility receipt) Date
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