HomeMy WebLinkAbout- Septic Pumping Slip - 315 BERRY STREET 6/17/2019 l::r,NREEJf
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COMM6 nwealth of Massadhusetts
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System Pumping Record
Form
DEP has provided this form for use by local 's of Health'rSystem Pumping Record must
e submitted the local Board Health or other approving authority.
A. Facility Inf
Important:
When f ffing out 1. Systern Location:
forms on the
cow titer, use 3�s
only the fib key Address
to move yourNorth Andover MA 0 1845
cursor-do not
use the return City/Town City/Town State Zip Code
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2 stem Owner:
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Name
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Address if different from location)
atyaown State de
Telephone Number
B. Pumping Record
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5— -1( 3 -(ci
1, but IMping t 2. Quantity �ped*
� Gallons
3. e:of'system- Cesspool(s) Septic Tangy; EJ Tight Task
1 Other(describe):
Effluent Tee Filter Present? El Yes No If yes,was 'it cleaned? s E] No
5. Condition of System:
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6. System Pumped By., 1
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Name Vehicle r.s.. l M r
Wind River Envirorkmentalh10
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Ott 7. Location40
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Signature of Hauler I is
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t5form4.doc#06103 Systern Purnping Record Page 1 of 1