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HomeMy WebLinkAboutSeptic Pumping Slip - 27 EAST PASTURE CIRCLE 7/6/2016 Commonwealth of Massochu ett City/-Town of 95 System Pumping Record NORTH ANDOVER Form 4 DEP has provided'th,s form for use by local Boards of Health. Other forms may be used, but the information must be substantially the snrne as that provided here- Sefore using this form,check with your local Board of Health tt3 determine the form they Ilse- 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 1 5.85'1. A. Facility Information Important: vJnen filling out `I- System Location, farms on they 4 Computer.Use 7, . only Me tab key Address "_ ".._ _'' •• ••- - td move your cursor-use the e4u r�i eilyfTown �— — ..-... .,. ., �........ _... State dip . _nt Godde key. 2. System Owner: Name AtltlYBSS if different from fgGatian --_' 8t. . � �ipGotle ee one Number __... ._. -.. , B. Pumping Record 1. bate of Pumping 2. Quantity Pimped: � .....---. -. Gatldns 3. Type of system: ❑ cesspool(5) Septic Tank ❑ Tank Tight 9 ❑ Grease Trap 0 Other(describe): 4. Effluent Tee Filter present? Yes §�-hto If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 5. 8ystern Pumped Sy-� Na'T Vehicle LPCense Number - Company - 7, Location where contents were disposed: Stgrrattsre of Hauler -- .. 8igr�arufe of Receiving PBClfity --- - tJate ,- ..�.._.- .-.'... ISformA.dbt-43/06 System Pumping Record-Psg¢ i of 1