HomeMy WebLinkAboutSeptic Pumping Slip - 374 SHARPNERS POND ROAD Commonwealth �
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System Pumping Record
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OEP has provided this form for use by local Boards of Health. Other forms
information must be substantially the same as that provided here. Befor e us|ngtk;��i�D�n�o0&��M your
local Board of Health ho 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 doba in
accordance with 310 CK8R 15.351. �
A. Facility Information
Important:When
filling forms 1. System Location:
~''---m`--' G POND RD
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key m move your Address
cursor'donot NORTH ANDOVER MA
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use the��m City/Town S�� �i
Code
*
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2. System Owner
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JAMES FARO
Name
Address(if different from location)
Qty/Town State Zip Code �
Telephone Number
B. Pumping Record
�
11/3V15 1500
1. Date ofPumping Date Gallons
Quantity Pumped: Ga|lono
3. Component: Ej Cesspool(s) E Septic Tank El Tight Tank F-1 Grease Trap
Fl Other(describe):
4. Effluent Tee Filter present? Ej Yes F� No If yes, was it cleaned? El Yes F] No
5. Observed condition of component pumped:
GOOD CONDITION
O. System Pumped By:
JAMES H CURRIER U H79 406
Name Vehicle License Number
J' SEPT\C & DRAIN
Company
7. Location where contents were disposed:
GLSD o'
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) oe0a
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