HomeMy WebLinkAboutSeptic Pumping Slip - 114 BOSTON STREET 2/14/2017 ~
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^���Mmonwealfhmf Massachusetts North Andover G��������t�
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City/Town«�vn� V
System Pump
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JOyVNOFM0FSHANDOVER
HEALTHDEFARTMENT
DEP has provided this form for use by local Boards of
Health, Other forms may beused, but the
form, check with
(hyour
local Board ofHealth todetermine the form they use. The System Pumping RononU must besubmitted to
|uoa| Board of Health nrother approving authority within 14 days from the Pumpingdate/naccordance with 310 CMR 15.351.
A. Facility
important:When ` —
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MU/nnouthu,mo 1. System Location,
enthe computer,
use only the tab
key tumove your Jdjr e s s
o«rso/-uonnr '
North Andover
key. City/Town
2. SysteLuowner,
--
Name
. State
��Code ----�---
er
B. Pumping Re
1 'Date of Pumping
bate 2. Quantity Pumped:
3, Component: Cesspool(s) -da 1�ns
Other(describe, EN"<eptic Tank EJ Tight Tank Grease Trap
4. Effluent Tee Filter p6t? Ye s El No
If yes, was it cleaned? IJ Yes No
5. Observed condition'
6. System
Stewarts Se Companyer
'
!
' Location. where~.. .
--
ord,
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Sign A of Haul r
signature -- ---
mmnn4.dou 11/12 \
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