HomeMy WebLinkAboutSeptic Pumping Slip - 1077 OSGOOD STREET 7/19/2016 Com L ib
monwealth Ulf Ma,,�sachusett�-UG
City[I own of North Andover
System Pumping Record
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DEP has provided this form for use by local Boards of Heal*h, Other forms may be used, but
information Must be substantially the same as that provided here. Before using his form
local Board off Health to determine the form - 9 , chi
the they use. The System Pumping Record rmus�,be
Lhe local Board of Health or other approving authority Lh
14 days within from the pumping date
accordance with 310 CMR 15.351. Lh I
A. Facifity Informati()n
Important:When
riling out forts 1. System Location:
Or?they ter
use only the tab
key to move your
cursor-do not
Address
use the return North Andover
key. CirtyTown "-----
Zip Code
2. System Owner:-cr
-biLiLh-
Name
Address m -------
ZF'iff�Own —'----
State
Zip Code
Tele.ohone Number
Pumping Record
Date 0) Pumping 2. Quantity Pumped-. alp
Date allons
3. Type of system: ❑ Cesspool(s)
El Other(describe): .
El S e ptic Tank ight T2nIk /GrEa�
4. Effluent Tee Filter present? ❑ Yes/O/k o if Yes, was ii cleaned? ❑ y�es
5. Cor) -kpn of System:
6. syst um ed By:
"y
Y' '5��4r
Name
Vehicle Uic'—en-s*e--N-u—mb-e-r-
SLewar-k's Septic Service
7. Location where contents were disposed:
S,Stewar, re-treatment plan, 4
tewart" re-treatment Plant. 20 So. Mill Bradford, Ma 01835
Sign u re of H u I e r
q-,
Date
Signature Tof Recejvjng-'Fa-61-'r-,I'y'- Date I I
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