HomeMy WebLinkAboutSeptic Pumping Slip - 107 ROCKY BROOK ROAD 8/5/2015 '
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City/Town of North Andover
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DEP has provided this form for use by local Boards of Health. Other forms may be used b��e
infnnna�Vnmust boeubebanbaUy the same as that provided here. Befoveusing �hiefo-` check vvithyn�
local Board of Health to determine the form they use. The System Pumping Record must` be submitted t
the local Board of Health or other approving authority within 14 days from the pumping� date in
accordance with 31OCyWR15.351,
A. Facility Information
Important:When
filling out forms 1- System Location:
on the computer,
use only the tab
key tv move your Address '�---�----�---�----�~���-�°��'-='' -- '���~�-�----------
cursor do not
use the return North Andover _____�_____ ___�_ __�_
�y. ^.w./own State zip Code-----------
2. System Owner:
Name - ---'---------
Address(if different from|natmn—_---'- -- ----- -------------'------------------
City/Town �---------�'-'�----'-- � ' ' ----'---------'--' ------'---------' |
State Zip Code �
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Date o1Pumping 2. Quantity Pumped: - �
3. Type ofsystem: Fl Cesspool(s) X Septic Tank Tight Tank [l Grease Trap
El Other(describe): ------'------------'-_---_-__-__'._'------
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4. Effluent Tee Filter present? F� No If yes, was ` cleaned? Yea No
5.
Nam
Vehicle License Number
tewart's Septic Service
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7. Lu:aum/ here contents |
Stewart's Pre-tre ent Plant, 20 So. Mill Bradford, Ma 01835
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System Pumping Record'Paga I of