HomeMy WebLinkAboutSeptic Pumping Slip - 17 WILDWOOD CIRCLE 7/9/2018 12""\ Commonwealth of Massachusetts
H x City/Town of No. Andover, MA � �" �7N E;11
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System Pumping Record
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms m4wul ;ib6 "
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,
use only the tab
key to move your Address
cursor-do not North Andover MA 01945
use the return _ — -- __ ...................
key. City/Town State Zip Code
Deb 2. System Owner:
Name
reaun
— ._.......... ..... ......... ..... _.. _.
Address(if different from location)
City/Town State Zip Code
_ ............ ... .......
..
Telephone Number
-----___.-
B. Pumping Record
1. Date of Pumping ! Quantity 2, Qtity Pum
Date ed:
Gallorld
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
® Other(describe): -.-_._.._... .. .. ____—_._...__ _.
4. Effluent Tee Filter present? ❑ Yes ZI- to If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
_
6. Syste _._Pu ped By: t __. ._....
1 .
Name Vehicle License Number
Stewart's Septic 58_So Kimb....... St.,
Company
7. Location where contents were disposed: j
zo so. Mill St., Bradfo WA
Signature either s — Date
—... ._... .. .—.._._._.. _— ._...�..............
Signature of Receiving Facility(or attach facility receipt) Date
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