HomeMy WebLinkAboutSystem Pumping Record C
COMrTildnWealth of Massachusetts
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j City/Tow' n' of North Andover (� MR
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System Pumping Record 10
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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 out farms . 1 System Location:
on the computer,
c
use only the tab
key to move your Add
cursor-do not
use the return T-b
key. City/Town State Zip Code
2. Stystern Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ..-Date 2. Quantity Pumped:
(1allons
3. Component: ❑ Cesspool(s) Septic Tank El Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter Present? El Yes [ No If yes, was it cleaned? 0 Yes El No
,7-
5. Observed conditipy of component pumped:
6. System Primp
Name Vehicle License Number
Stewarts tic.58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
�ignature�aHau�erDate
Signature of Receiving Facility(or attach-facility receipt) -Date '
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