HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 8/24/2015 °
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Commonwealth of K �sachusefts
,
City/Town of North Andover
System Pump^ng Record
Form ^~
DEP has provided this form for use by local Boards of Health. Other forms may be uued, but the
information must be substantially the same as that provided here. Before using this form, 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 CPWR 15.361 �
A. Facility Information
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Important:When
fiUingout forms 1� System Location:
nn the computer,
use only the tab '
key m move your Address ������----'------------'-------- ----'- --
cursor'uonot
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�e����m orth Andover --_-_ _---_--
xey. ^"r'~=' State Zip Code
2. System � 6 &
mame // -- �7-------- --'-'---------------------
��---
Address(if different from location)------------ - '------'--'------'-----
���____-_'__--_-- --' __ �
City/Town ���_ _ ��Cn4e
-- -__w_________-_ |
Te�-�_�evmber
B. Pumping ^~~~~~^"~°
-
1. Date ofPumping Date 2. Quantity Pumped: --
Gallons
3. Type of system: El Cesspool(s) Septic Tank El Tight Tank El Grease Trap
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Other(describe): -------'------- ...-.........
----------''----- -_
4. Effluent Tee Filter present? F� Yes El No If yes, was if cleaned? Yes No
5. Condition of System:
5. System Pumped By: �
Name Vehicle License'---'-----
Number
Stewart's Septic Service
Company �-------- --' '—
7. Location where contents were disposed:
Stawarfe Pre-treatment Plant, 20 So Mill Bradford, 01835
Signature ofHauler ���-'------------ --------''-'' ------Da
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System Pumping Record'Page 1m1