HomeMy WebLinkAboutSeptic Pumping Slip - 248 BRIDGES LANE 6/10/2015 ~
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Commonwealth of Ma,,�sachusetts
City/Town of North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, butthe
information must be substantially the same as that provided here. Before using this form, check with your
local Board nf Health to determine the form they use. The System Pumping Record must be submitted k)
the local Board of Health or other approving authority within 14 days from the pumping date in |
accordance with 8YOCK8R15.351,
A. Facility Information
Important:When
filling 8yohamLooebon�
on the computer,^ � � JUL
�eon�the�b d ���.
key to move your
Address - �� -T�0MQFNOR�HANDOVE�
cursor do not
use the return North Andover
HEALTHDEPA����NT
-------------' ---'---- - ----- -_-_ __ __--_--_______-__
key, City/Town mate Zip Code
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2� System Owner:'
'��mn -- - ------ --' --------- —'--------------------------
------- Addn=ns(if-different fro r_1ocaVpn-------- - -' -- -------------------------------------
City/Town �����---------------- --' ' State----------- Zip Code
Tel�pTonwumber
B. Pumping Record
1 Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: F-1 Cesspool(s) N� Septic Tank El Tight Tank El Grease Trap
El Other(describe): --------------------------- ------ --
4� Effluent Tee Filter present? Yes No If yes, was ' cleaned? Yes E] No
5. Condition ofSystem�
Af~ ~
O --
-�------ Vehicle License Number
�---'-----------------
Company �--------------- --- --
Y. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill_Bradford, Ma 01835
��natore of*oule, -------------- ���-----'--' ----'-- --
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Signature of Receiving =uomty '—'-- --- ----- Date�------------ — -----------------
t5m�4.doc-03/06
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