HomeMy WebLinkAboutSeptic Pumping Slip - 1725 TURNPIKE STREET 3/12/2013 E'
Coinrnonwealth of Massachusetts
&I City/Town of NO. ANDOVER 09 �?013
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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 forrrr, 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 1. System Location:
forms on the
computer,use 1725. _....._ ...._.. . --— --
only the tab key Address
to move your NO. ANDOVER MA 01 845
cursor-do not ------ ----
use the return City/Town State Zip Code
key. 2. ,System Owner:
ALPRIME GAS
Name
------------ ---- ------- --- -----_.. ------ ------._..-- ------ -- ---- ----— .. .._..
Address if--different from location)
--------------------------------------------------...------.._..-- _...._. ---......--------------------------------- –....._.. .._............
Ciky/Town State Zip Code
Telephone Number
B. Pumping score
3/12/13 1500
1. Date of Pumping -Date G--- ---- 2. Quantity Pumped: allons.-I- - _
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
G. System Pumped By:
JAMES H. CURRIER H79 406
Name Vehicle License Number
J's SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
--- ......
3/'12/13
Signature of Hauler Date
---._ --- --_ –
Signature of Receiving Facility Date
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