HomeMy WebLinkAboutSeptic Pumping Slip - 107 LIBERTY STREET Commonwealth Massachusetts
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City/Town �f RECEIVED
�� Pumping �������
~��~~~~ , ^_,,,�� Record, ~~ NOV 1 � Y0� -
ForQ� �� '`~' ' � "�.J
TOWN
OEP has provided this form for use by local Boards of Health. Other forms m8K��
information must be substantially the same as that provided hen*. Before using this form, check with your
local Board of Health to determine the form they use. The Gyebsm 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 CK8R 15.351.
A, Facility Inforrnat^on
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 107 LIBERTY STREET
key to move your *uumen
o«m»r-Uonpt NORTH ANDOVER MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
�---~ L{}U|GCARR|LLO
Name
--------
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
11/3V15 1500 �
1 Date 2 Quantity Pumped:' Date � ` ' � oo||one �
3. Component Cesspool(s) M Septic Tank El Tight Tank El Grease Trap
Fl Other(describe):
4. Effluent Tee Filter present? El Yes 0 No If yes, was it cleaned? F-1 Yes El No
5. Observed condition of component pumped:
GOOD C(Jw)|T|00
8. System Pumped By:
JAMES H CURRIER || H79 406
Nome Vehicle License Number
J' SEPT|C & DRAIN
Company
7. Location where contents were disposed:
7
Signature Of FlMiler Date
Signature of Receiving Facility(or attach facility receipt) omm
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