HomeMy WebLinkAbout- Septic Pumping Slip - 37 STONECLEAVE ROAD 5/13/2019 t
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AND)OVER MMSSACHUSETTS
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System Purnjmrig Record
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DES" has j)rov de h cs form -for us y lo,ca,l Boards of Health. The System Pumping Record, must
e submitted to the local Board of Health er approving authorlty,
A. lr'mac"Efiolty Informatiorl
Important:
When filling out System Location:
forryis on the �~
computer,use
onily the tad key Address
to rove yoLr North Andover MA 8145
cursor-�� rant _���_ .. .,��_.�_ ���,® ����.���..a_..._..®_�.m
use the return Try, State Zip Code
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2. S stern Owner:
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gym.
10 b
['14"M
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Address(if different from location)
1
ie hone Number
B. gi Record
Da f Purn ping
W Date. Gallons
Cesspool(s) GepticFank Tight Tank
Other
,.. -Effluent Tee F1111ter present? Yes 1 If cleaned? "
5. Condition of Sys tern:
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6. System Pur e Bye
� r I 14
Li q
Wind N er Env r -nen l der,
Company ARM0
rd, A,4 c4l
(97.9) 4 0
. Location where contents were disposecl,
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Date,
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t5form4.dc1c,,06103 System Pumping Record-Page 1 of 1J
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