HomeMy WebLinkAboutMiscellaneous - 0 INGALLS STREET 4/30/2018"� 3 p
C ReCo�d AUG - 2 2007
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i a A04
TOWN OF NORTH.ANDOVER
t7EP. has provided this form for use by local Boards of Health. Th ' cord must
be submitted to the local'Board of Health or other approving author(ty,
A. Facility Information
-ImRortantt
s,,,Wheh r�w,fl out 1 : System Location
forms to
;• c«nputer use I
only the tab.key Address
to move your._;Aw
a,raor • do not CI /Town
usa the r@tum tY State
Zip Code
1s
kaySystem Owner, J
fj
Name
Address (If different from location)
Clty/Town State .
Zip Code
C.
Telephone Number
6.`Putnping Record
1 ,ti 4, i1, 1, 4.+ ,fa J�ui �'�" + 1 � �_r--•
,a Date of Pumping oat 2. Quantity Pumped: j
1
G Ilons
Typ' of system ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑' Other (describe);
4 Effluent Tes Filter'pre..ent? . ❑ Yes oIf yes, was if cleaned? ❑Yes ❑ No
ono S st
8 Sy em Pumped By:CZ
.'
r Name
` � x `� ° 4 ^ ��`� 1��;`� �� X9'1 %��{ ll' 1 t'U �1/l' '/ � • � � r /h/i nn/Vehicla Ucan$e Number
t ,Y..y,.- Vn. %> Y 1. 1 1 r t •Id c '' . ^Y'. ��r�l
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7, Location where` contents were d(;3posed;
fI G
i. !I
J , ' , ; ' �,� , �•1 S(Dn a of Hauler,: j, �..
httpJh+vwVv. mass.gov/dep/wateNapprovals/t5forms, htm#Inspect