HomeMy WebLinkAbout- Septic Pumping Slip - 3/4/2019 -ionvvesifth Of Massachusetts
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DE:P has provided this farm for tit;e by 10carl Boards of Healtil, The System Pumping Record must
be submittecl to the locat Doar'd of Health or other approving authority.
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Importzrrt:
When filling out 1, System I_acaiian:
forms oil the
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puler,use ,r,� ( i t r ,l I F ,t r � , l,r i•
only the tab key F�ddress r' ` �'`,
to n•rave your
North Andover
cursor-c!o not _ MA use the return Clty/Town .__.._._._ ___..__. .__..,___ _._.
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key 01845
Stake Zip Code
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_
Name
1
Addres.,(if different from
City/Town _.-
Zr Cede
Telephone Number --- _---
1. Date of Pumping _ -_��
bate 2. Ouantity Pumped:
Gallons
3. Type of system: [-:J Cresspoai(s) C_J 3eptic Tank
Tight Tank
,,Other(describe):
4. Etfiueri Tee Filter present? Cv9 Yes No If yes, was it cleaned?
D `des ❑ Na
5. Condition of System:
6. Systern Pumped ley:
Vehicle Wind Llconsr Number
Aver Environmental
7. Location where contents were disposed:
•; ; ; SEPTIC SERVICE
�_KIMBALL ST.
,
I:Mf1AI FORD, MA 01835i_____
Signature of Flaulrr ,„
httla://wwvv.rrkass.gL-,v/dep/water/a pp.r
ovals/i5farn'rs.htrrAnspect
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t510rm4.doc-G6/03
System Pumping Record•Page 1 of 1