HomeMy WebLinkAboutSeptic Pumping Slip - 531 FOREST STREET 8/28/2015 - - '
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Commonwealth of'K8a � sachWsetts D
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City/Town of North Andover
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System Pumping Record
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TO�NCF�0RTHA� J0V�R
Form '
HE�JHDL�/5�ENT
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DEP has provided this form for use by hoa| Buenda of Health. Other forms may be uaed, butthe
information must be substantially the same eathat 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 310CNlR15.351,
A. Facility KU0for00at'o0U
important:When
filling out forms 1. System Location:
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key m move your Address
cursor-do not
North use the return
------------- ---'--''- ' -----------'--- ------------------
key. City//own State Zip Code
2 System Owner: � &
— no so�-)
Name '-7-------'-------------- -------------------------------------
-------
Address(if different from�Toowuon ------------ ----'-----------------'----- --
CityDown ---'--'---'— -' State-------------- Zip Code
Telephone Number
B. Pumping Record
'. Date of Pumping D5� �� Quantity Pumped,-
G611onn
3. Type of system: El Cesspool(s) 1,4 Septic Tank El Tight Tank El Grease Trap �
/
El Other(describe): --''—'---'--
4. Effluent Tee Filter present? Yes Fl No If yes, was itcleaned? Yes E] No
5. Condit'
O. Rystem P dB
Name � Vehicle License Number
--- �
Stewart's Septic Service
Company ���-------- '--
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
ignomrenfHauler -���----------' ���-----'-- ----
SignammofRecoivinuFacility ----- — '---' ' Date---------'-- —
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