HomeMy WebLinkAboutSeptic Pumping Slip - 121 CAMPBELL ROAD 8/28/2015 ° ^ � ^
Commonwealth + Ma � rhusetts R "����
C'Ly/ JAy of North Andover
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System ��u00�^�� R�����d ~^'
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DEP has provided this form for use by local Boards of Health. Other forms may be ueed, 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 |moa| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310CyWR1S.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, i-
voeon|ythetyb 2
key m move your Address �������------'------------------- -----
cumu,-uomot
use the return '`~'~' Andover
-__-- ------- ___-----__-_--- ----
key. °"r '=n/ State Zip Code
2. System Owner:
Name ' �------------'-----'--------------
��------
Address(if different from,location)
----'--- --- ----'—'---'------------'---- - |
Citynown ��-------------- -- S�te-'------'------ --Zi
-- ----'
~_. .Pumping Record
/16 �
1. Date of Pumping ��------ �� O��� Pumped.- --Gallons
3. Type Vfsystem: |(s) vi I Septic Tank F_� Tight Tank El Grease Trap
�
�]
Other(describe): -------'-'----------------------'-------- --
4. Effluent Tee Filter present? F Yes Fj No If yes, was- if cleaned? Yes No
5. Condition ofSystem: �
�����'
6. System Pumped By:
Name Vehicle----'----'------- �
License Number
Stewart' Septic
Company
---`---- --` ' --
7. Location where contents were disposed:
Stewart' Pre-treatment- -� '~ ~~ ` '~~` |
-----'----- |
Signature ofHauler --------''-- ------
S7,gnatureofRaoa*no �o� ----- — ----' ' ���---------''-- ' ---------------
mm�4.doc-03/06 System Pumping Record-Page 1 of 1