HomeMy WebLinkAbout- Septic Pumping Slip - 102 LACY STREET 6/17/2019 . �� ��!r/fE'Jr�ArJ'��r�/��'!, ��✓�1WilJ//�/�lI
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System Plumping Record 1-1 Ef"�L""I I- ["'Y'I "I"�,'Vl I I"I""'I'
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Form 4
CEP has provided this form for use local Boards Health. The System um in,g Record must
be submitted to thieI Boar al r other approving aI� i
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A. Faciflity Information
Important-
When filling out 1 System Location:
R-)
forms,on the
computer,use Ql—�c;e clz
only the tab key Address
to move your North Andover, MA 01845
carer-do not Ott Zip Code,
use the return City/Town
2. System Owner: �
M
._ Name
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Address different"from location)
State Cod
City/Town /?
0,0�
Telephone Number
B. PUMPIng Record
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1
1. Date of Pumping ..Date 2. Quantlity Pumped., Gallons
3. system- C s�: Il sKSepticTank
1
E] Other crier No
i
Tee Filter present.? Yes No If yes,was it cleaned? Yes El No
5. Condition System:
1
. System Pumped
GjqZ S7)
Name Vehicle License Num
Wind River Environmental
n
w11WWT," .
7. Location where contents were disposed:
Ipswich q
Signature of Hauler Date
t5form4.dcce 06103 §ystern Pumping Record w Page I of 1