HomeMy WebLinkAbout- Septic Pumping Slip - 160 CARLTON LANE 5/2/2019 I
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City/Town of N O T ANDOVER.
System Pumping Record
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1,Form 4 j:AC-A 1
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DEP
has provided this form for use y local cards f lit . Other forms may be used, but the
information must be substantially the same as that provided mere, Before using this fora, check with your
local Board of Health,to determine the fora they use. The stem Pumping Record r rust be submittedt
the, local Board of Health or other approving authority within sir 14 days from the pumping date, in
accordance with 3110 CMR 15.351.
A. Facility Information
Import nt:When
filling out forms 1. System Location:
on the COMPUter,
use only the tabs
key to move your Address
cursor,-do not NORTH N VE A 01845
use the return Ivey.
City/Town �
to
2. System,Owner*
DARRENWINNIE
Name
a
few
Address If different,from location),
u
lit /Tows Stag Zip Code
1
0
Telephone Number
B. Pumpingd
�I9 � 5
1. gut f Pump in Date _ � , Quantit Pumped: �
Gallons
3. Component: [:1 Cess loI si Septic Teak El Tight t Tank Grease Trap, s
0
E]
Luther(describe) 4 M
was it cleaned? Yes N
Effluent ` e FilterFilterr + r�t ` "es I' Iyes,
5. Observed condition of cornponent um
p
GOOD
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6. System, Pumped
JAY'CURRIER H79406
Naas Vehicle License Number
TS SEPTIC & DRAIN
Company
7. Location where contents were disposed:
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