HomeMy WebLinkAboutMiscellaneous - 12 BACON AVENUE 4/30/2018 (2) J 12 BACON AVENUE
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SL� Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
Form
provided this form for use by focal Boards of Health. Other forms may be used,but the
DEP information must be substantially the same as that provided here. Before using this form.check with your
local Board of Health to determine the form they ttse.The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31 o CMR 15.351,
A. Facility Information
lmp°rxant: 1. System Location:
when Ving out Y
forms on the
computer.use
only the tab key Address
to move your .lf/ _ Gtic �
cursor-do not _• State Zip Code
use the return
CityfTown
key. 2. system owner:
Name..... �' . ... .�.. .... _._.. .., ., --...
A�ARAddress(it different from location} „
-- Stele Zip Code
CityJTown /L�7.•�i��
--
13. Pumping Record ��•��
�( 2. Quantity pumped: Gauons
1. Date of Pumping Coate
3 Type of gygtem: Q Cesspools) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ other(describe): - - - ---
4. Effluent Tee Filter present? ❑ Yes ❑ No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of stem:
oorz-
6. System Pumped By: -
_—J LIcense Number
company
7. Location where contents were disposed'
Slgr�aSurQ�Y`.��• --. �~ •pat's
$ignalure of Receiving Facility
system Pumping Record•Page 1 of f
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