HomeMy WebLinkAboutSeptic Pumping Slip - 10 HAWKINS LANE 2/9/2016 ^ '
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Commonwealth of Ma,,�sachusetts
C)'tV/ oVn of North Andover
-System` Pu0p^ng Record '
Form 4
_
DEP has provided this form for use by |uoa| Boards of Health, Other forms may be uaed, but the
information must be substantially the same as that provided here. Before using this form, check with �
local Board of Health to determine the form they use. The System Pumping Record must beauhmitta
the local Board of Health or other approving authority within 14 days from the pumping date in |
accordance with 310 C[NR 15.361.
A. Facility information
Important:When
nMing out forms 1 System Location:
on the computer,
use only the tab /L» _____
k��mmeyour Address
cursor-uonm
North
-
vme�ereturn
key. city//own State Zip Code
Z System Owner: �
Name
..... -' ' -'---' ---------i~zT-�'f�-+FM~ --------
odd�os(�ume�ntonmlocation)
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City/Town State 'L?! [_ 2ip Code
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------------'----
Talephonewvmber
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date on�s
3. Type ofsyehem� Fl |b6 Septic Tank El Tight Tank Fl Grease Trap
`
U Other(describe): ---------�'�--'------------
4. Effluent Tee Filter Yes E] No If yes, was it cleaned Yes No
5. Condition uf5ystem:
8. t R ,
wamn - �__-- � ��------------- --'------------ ------
Vehicle License Number
Septic Service
Company ���------ -'- '-
7. Location where contents were disposed:
Stewar[o Pre-treatment Plant, 20 So Mill_Bradl'ord^Ma01835
Signature mHauler —'�----�-'----' Date-----''-'' ' ...........
-------'------
��namrevfReoewngl:isc�y - -- - ' -- ����---- ----'- ------------
n�nrmwum,oamo
System Pumping Record'Page 1 o