HomeMy WebLinkAboutSeptic Pumping Slip - 646 FOSTER STREET 8/31/2015 commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form A
DEP has provided this form for use Joy local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this foam, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15.351,
A. Facility information
Important:
Wh !en filing oui � System Locations'
forms on the
composer,use
only the lab key Addre /�_� Q LIC
io move your A"- d. �� ��. p Code — -
Cursor-do nol -- - „.._...,.,. stale
Zip Code
use the reiurm Cilylfawn
Rey, 2. S ern Qwner: /
Name
�,.o Address(ft different from location}
Zip Code
Teiegtxpnc Number
F3. Pumping Record
-` 2, Quantity Pumped,
1. date of Pumping Dale ms
3. Type of system: ❑ Cesspool(s) BApiic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe).
4. Effluent Tee Filter pre 2 sent? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No
5, Condition of Byste :
6, System !dumped By:
Wind River EnVhVU8=tW
Vehicie L icerLra Number ++
Carnpany
7. Location where contents were d �
isposed: 0 - '..,...
5i r of Hauler date
Signatur¢❑t Receiving Faciiity ^ ._.. . _.. - pate
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