HomeMy WebLinkAboutSeptic Pumping Slip - 71 PENNI LANE 11/22/2016 Commonwealth of Massachusetts
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System Pumping Record
Form 4
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 form, check with your
local Board of Health tn determine the form they use. The SyaharnPum�:./,, 172c~rri must bm submitted to
the local Board of Health nr other approving authority within 14 days from the punm�'ing date in
accordance with 31OCyWR15.351.A. Facility Information
Important:When RECEIVED
filling out forms 1. System Location: Nu "
.
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on the cnmpme' . �°
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use only the tab 71 E
key vomovoyour xnpnv,» — ~°m'
cursor'donot NORTH ANDOVER MA HEALTFIC1315,W
use the return City/Town State Zip coua
key,
2. Gvatenn Owner:
- u---� PETER D|BENE0ETT{}
Name
�
It State State Z�Code
C �rown
�Iephone Number
B. Pumping Record 11/22/16 1000
1. Date nfPumping Da0a 2. Quantity Pumped: Gallons
3. Component: El Cesspool(s) Septic Tank El Tight Tank Grease Trap
Fl Other(describe):
4. Effluent Tee Filter present? E Yee No |f yes, was itcleaned? Yee No
5. Observed I condition of component pumped:
GOOD CONDITION
G. System Pumped By:
JAMES H CURRIER |\ H79 406
Name ,=,,.~.~,^.,,.,.,.,_
|
Company
|
7. Location where contents were disposed:
GLSD
� Date
� facility receipt) Date
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