HomeMy WebLinkAbout- Septic Pumping Slip - 2147 TURNPIKE STREET 6/17/2019 01
Ell: 0 Commonwealth of Massachusetts REC
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Cityffown� of NORTH ANDOVER
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System Pumping Record ,, N"Ityi)A
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DEP has provided this fora for use by local Boards of Fleallth. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with, your
I c I Board of Health to determine the,fora they use. The System Pumping Record rust be submitted to,
the local Board of'Health or other approving authoritywit iin 14 days from the a in date I
accordance with 3110 C R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the cornputer,,
use only the tab ,..
key to o your address
cursor-do not NORTH V N�1 5,
use key.the return fit ,,,.. ,,,, .. .�,... ..
State, Zip Code
tab 2. System Owner:
GEORGE MEAR
Name
Address i iff r nit from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1I Date of Pumping �6/13119 . QuantityPumped: 1500
DateGallons
3. Component: F1 Cesspool Septic Tank Tight Tank Grease'Trap
F Other(desicribe):
4. Effluent Tee Filterpresent? Yes No It yes, was it cleared? E:1 Yes El No
5. Observed condition of componentpumped:
FOOD
. System Pumped
JAY CURRIER 9 6
1me VehicleLicense Number
J'S SEPTIC & DRAIN
Company
. Location where contents were disposed:
S ,
13 9
�i t !re of Hauler Date
Signature of Receiving Facility or attach facility receipt) Date
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