HomeMy WebLinkAboutSeptic Pumping Slip - 651 TURNPIKE STREET 8/15/2017 `
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Cbmrridnwealth of Massachusetts --
C of North Andover
S�ystern Pumping Record
DEP has provided this form for use bylocal Boards ofHealth. Other forms may boused, but the
information must bosubstantially the same esthat provided here. Before using this form, check with your
|oom| Board of Health to determine the form they use. The System Pumping Record must be submitted to
Ahe local Board of Health orother approving authority within 14 days from the pumping date in
accordance with 31OCMR 15.351.
A. Facility Information
` When .
1. System Location:
on the computer,
use only the tab
key mmove your Address
cumor-do not '
use the return
key, ""y''"~" State Zip Code
2. System Owner: '
Address(if=different fro
°°�=v
City/Town State Zip Code
'
Telephone Number
' B. Pumping Record
1. Debs of Pum 'ng2� {]nant�v Pumped: Woo
DateGallons
3. Component: �l (s) E] Septic Tank Fl Tight Tank El Grease Trap
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^
L�~ Other(doscrbe):
4. Effluent Tee Filter present? r-1 Yes If 0 Yes El No
5. Observed condition ofcomponent pumped:
8. System P
Name Vehicle License Number
Stewarts
Company
7. Location where contents were disposed:
20 so nn||| otbredfond nnm
Sibnatur,63f Hauler Date
Signature of Receiving Facility(or attach facility receipi�)- -da-te
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