HomeMy WebLinkAboutSeptic Pumping Slip - 45 SUGARCANE LANE 8/29/2016 Commonwealth 09 Massachusetts
City/Town of North Andover
SYstem- Pumping Record
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DEP has provided this form for use by local Boards ofHeal',�h. Other forms may be usec
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information must be substantially the same as T
that provided here. Before using this-om
local Board of Health to determine the form They Lj�se. The System Pumping Record mu,,
the local Board of Health or other approving authority within. 14 days from the Pumping
accordance with 310 CM R 15.351.
A- Facility Informabon
Impo-'Lant:When
511ing put;oils 1 System Location:
on'the c6mout ter. Kk
use only the tab C.
key to move your 'Address
cursor-do not
use the return North Andover
key, To_n
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Z�_' /� Zip C'
Z Sys-em Owne
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Address(iT d'rerent from location
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State ZiP Cc
i elephorie Number
Pumping Record
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1 Date of Pumping ..........
Date 2. Quantity Pumped:
Gallons
3. Type of system
❑ Cesspooi(s) [1J"'S6pLic Tank
❑ Tight Tan; ❑ C.
❑ Other(describe):
..............
4. Effluent Tee Filter present? ❑ Yes [3"'No !i yes, was it cleaned? Yes
5. Condition of System:
0. Sys t Mped By
&
Name
Ve�_Icle__Ucense number
Stewart's Septic Service
company -
Name,—
7. Location where contents were disposed:
wartt's Pr eatmer
Ste
�t�negt.Rjqq 20 So. mill Bradford,B Ma,01835
20
'ur""ri
i9natur '0`1"Mauler
- Sign2— lure of 2 70
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Receiving y Date .......