HomeMy WebLinkAboutSeptic Pumping Slip - 745 FOSTER STREET 5/12/2016 e\
Commonwealth m� ��Massachusetts
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City/Town of No Andover --
System Pumping Record 11/'d
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HEAL THOEPARTYENT
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 hone. 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 15351
� . �
A. Facility Information
Important:When
filling out forms 1. System Location:
on the
use only the tab 745 Foster
key m move your Address
cursor-do not
North Andover MA
use the return
key. c/tyf/mwn State Zip Code
|
2. System Owner: /
^----� Me m �
mamo
�
Address(if different from location)
u4^/own State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping 2 Duantdy Pumped ' ~--
uma � � oo||onn
3. Type ofsystem: [] Cesspool(s) U0 Septic Tank [l Tight Tank 0 Grease Trap
[I Other(describe): �
4. Effluent Tee Filter present? 0 Yes 1�j No |f yes, was itcleaned? F-1 Yee 0 No
5. Condition of System:
0. Gynham Pumped By-
Name ' / Vehicle License
Stewad's Septic Service
Company
7. Location where contents were disposed:
Shawmrƒo Pre-treatment Plant, 20 So K4iU Bradford [Wo 01835
Signature ofHauler Data
Signature of Receiving Facility Date---- �
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