HomeMy WebLinkAboutSeptic Pumping Slip - 10 LIBERTY STREET 8/12/2015 . . - '
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Commonwealth ' Ma � sachuseft `
��' �� North Andover
City/Town[]���� `�/ x�CJ. ' /
System Pumping Record S[_P O U '
Form 4
T0VNCFNOFUH�:DD`/ER
DEp has provided this/onn for use by local Boards of Hea -~ay be used. butthe �
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 31OCK8R15.361. �
�
A, Facility Information �
Important:When
filling out forms 1 System Location.-
on the computer, �
use only the tab
key mm�eyour Address / -------' - ------------------
ounmr-unnm
North~~'' `''~~`~' ---------�---- ---�'_-.._ ' _ -____-_-__-__ ------__-_--------
�*. ~.yv.vwn State Zip Code
WQ Z System Owner:
Name_ --'___-_-�--_---. -___.--_-_____-_.'
�------
Address(if different from_foou�un ----- ---- --' '----- -------------------------------
City/Town -------- '------'-- ��- ���ate-------------- Z�,Code
----------- |
�
Te|���wwn�r
B. Pumping "~~^~~~"~°
c_�
1. Da� ofPum�ng ---------'-- 2 Quantity �um��� ~� ---
Date � � ga|mno
3. Type ofsystem: El (s) Septic Tank [l Tight Tank El Grease Trap
`
L] Other(describe): -----'------------
'------------_ _
4. Effluent Tee Filter present? E] Yes [l No If yes, wasitoleoned? FJ Yes F-1 No
5. Condition ofSystem: /l
b. System Pumped By:
Name --------'----
Vehicle License Number
Stawaff s Septic Service �
Company ���---'---' --- '— -
T. Location where contents were disposed�
StewarCe Pre-treatment Plant, 20 So. Mill_Bradford, NaO1R35 ______________
Signature ofHau|er Da
���-'-------'---- --------''-'' - -----
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