HomeMy WebLinkAboutSeptic Pumping Slip - 290 BARKER STREET 7/9/2018 17���������
Commonwealth Massachusetts w*����w� ���
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City/Town
^Ty/ own ofNo. 1O 2018
System Pumping
Record����u�K� " ������� n�����n � ��QPNORTHANO(�E�
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Form �
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
|uoe| Board of Health to determine the form they use, 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 310 CMR 15.351.
A, Facility Information
Important:When
filling out forms 1. System Location:
onthe computer,
use only the tab "
key mmove your ^guoaon
cursor-do not
North Andover MA 01945
use the return
key. City[Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Stam Zip Code
Telephone Numberi
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: ......
Date Gallons
� �
3. Component: F� Cesspool(s) UopticTonk E] Tight Tank [l Grease Trap
F Other(describe):
4. Effluent Tee Filter pmaaeny7 El Yea [)O No If yes, was it cleaned? Fl Yeo [l No
5. Observed condition nfcomponent pumped:
U. System p mped B
Name r ~- Vehicle License Number
_,qtewarVs S tic 58So. Kimball StBradford,MA
Company
7� Location where contents were disposed:
20 So. W1U| Bradford, MA
Sig Pa�t4ureau—ier Date
Signature of Receiving Facility(or attach facility receipt) Dam
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