HomeMy WebLinkAbout- Septic Pumping Slip - 555 FOREST STREET 6/17/2019 E D
LN 0,m- m o n we
alth of Massachusetts
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City/Town of NORTH MASSACHUSETTS,
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UP System Pumping Record
Form
,a, 1
DEP
has provided this form for use by local Boards of Health The System Pumping Record must )r
be Isubmitted to the local Board of Healthr other approvilng authority.
A, Facility information
When filling out I System Location:
forms on the
,e
computer,use
only the tab'key Address
to move your North Andover MA 01845
cursor-do not CityfTown
_ State Zip Cody
Use,the return
a
.w
2* SystemOwner-.
a
,u
o ,. Nerve
Address(if different from location),
CityrTovm State Zip Code,
"It, Cl 73 7 3 T-3
Telephone Number
B. Pumping Record
1. Date of Rumping Date '. Quantity Pumped-'
3. Type of System: El Cesspool(s) [��S,eptic'Tank El Tight'Tank
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Other escri
1
rat Tee Filter resat' Yes 91 No If yes,was it cleaned? Ej Yes E] No
5. Condition System
6. System P mead
Z .
Vehicle License Number
l� r
Wind erEnvironmental
Co verhill WWTp
Porter'S7. Location where contents were disposed: 40 S
Bradfor
7 * 32
Siginaturabf PHa er
Date
t5f -�06/03 Systern Pumping Record-Page 1 of 1