HomeMy WebLinkAboutSeptic Pumping Slip - 60 RALEIGH TAVERN LANE 10/19/2015 - '
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Commonwealth ofMa8 achusefts
City/Town of North Andover
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Pumping Record
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System . �K����� ^�����n �
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as-that provided here. Before using this fonn, 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 dab* in
accordance with 31OCPWR15.351.
A. Facility Information � �--�-------
important:!VVhen
filling out forms 1. System Location:
on the computer,
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key. City/Town State Zip Code
l System Owner: �
VQ
wame �� � ---------------'-----------'-----
------- Address(if different from location)
��-----'---- -'---'—'----------------'----'
oitynvwn �--- ------- - - State------------' Zip Code |
Telephone Number �
B. Pumping Record b
1. Date of Pumping 2. Quantity Pumped.
Date ^� Gallons- |
3, �����m: � Cesspool(s) S� SeoticTank El Tight Tank El Grease Trap
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Other(describe): --'-----------------
-'--'---�-------------'----' ---
4. Effluent Tee Filter present? Yes No |f yes, was itcleaned? F-1 Yes F7 No
5. Condition ofSystem:
6. tem Pumped By:
Name x Vehicle License Number
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Stewart' S
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Cmmpony �---------- ----
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7. Location where contents were disposed: �
G /
Mwuhv
of ����----------- --------- --- ------
Date
dignomm of RnoeivingFac| x----- --------- ���------------
'-- - -
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