HomeMy WebLinkAbout- Septic Pumping Slip - 70 LIBERTY STREET 5/8/2019 amH+lift
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Commonwealth oii Massachusetts
City/Town of No. Andover
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DEP s provided this form for use y local Boards of Halt w Other forms may be used,, but the
information must be substantially the same as that provided here. Before using this fora, check with your
local ,Board of Healthto determinethe form they use. The System Pumping Record must,be submitted t
the i i Board of Healthr other ier u r °inn authority,wit in 14 days from the pumping date in
accordance with 310 CAR 5.35
A. Facility Information
Important:When
filling out forms 1. System Location:
on true computer,
use only the tab
key to mug your, Address
cursor_do not No.Andover
use the return � 5
City/Town
/TownCode,
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key. state' Zip Co �e,
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2. System Owner:
Name
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1
. .
Address(if different,from location)
City/Town State Zip Code
Telephone Number
B. Pumpling, Record,
00
1. Date Pumping �urtt
Date G Ilia
3. Component C ss I s I tip � Tight TankGrease,'Trap
Other,(describe).-
4. Effluent Tee Filter present? El Yes0`1�� It yes, was it cleaned El Yes N
5. Obs,erveld condition of component pumped:
w Sy tern Pumped
Vehicle License Number
Stewarfs geptic 5,8 So. Kir ball St. Bradford MA
Company
7. Location where contents were, s :
2 , , . Mill St., BradfoLd, MA
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Sr nit of hauler
Signature e i in Facility(or attach facility receipt) Cate
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