HomeMy WebLinkAboutSEPTIC PUMPING SLIP (2) � ^ ~
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Commonwealth 6T ma,�sac
usetts
City/Town of North Andover
System Pump~ng Record
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DEP has provided this form for use by local Boards of Health. Other forms may be used, butthe
information must be substantially the same as that provided hone, 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 CyWR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key m move your Address
ovrsnr-uonnt
North-`h
Andover ------------- --- '--''- ' -' '----........-----'--- _-----------'--_
key. City /own mate Zip Code
2. System Owner-,
Name ~�-��-------'-- --- ' ' ---------------------'-----------------
-------
Address(if different from wcaoon'----- ---- --' '----'-------------------------------
Cuy/Town -�------- '---''-'-- � - 7State-----'--------' Zi,Code
----------
___ __________
Te�p_w=wu��r
B^ Pumping Record
J
1. Date of Pumping � - 2 Quantity —
uo� � � Gallons
3. Type ofsystem: Fl Cesspool(s) SeodcTank El Tight Tank Fl Grease Trap
E] Other(describe): -------'-------------'-----------''-'------ --
4. Effluent Tee Filter present? Fl Yea Fl No If yes, wasifcleaned? F-1 Yes El No
5. Condition of System:
�����-----�'7-------'--------------
h. System Pumped B\( - '--- --___
Name --Vehicle License Number
---
Steweff s Septic Service --`
Company ��------- --- '-
7. Location where contents were disposed:
Stewa/ƒm Pre-treatment Plant, 20 So Mill Bradford, 01885
S�na�mnrHauler -'----------- ����------''-'' - -----
Signature nf Receiving Facility ----- -' '-'-' ' Date-------''-- -
mmrm4.doc-03/0 Pumping Record'Page Iof1