HomeMy WebLinkAboutSeptic Pumping Slip - 31 OXBOW CIRCLE 11/16/2015 ' ^
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Commonwealth nfMa � sachu
City/Town of North Andover
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Syst m Pumping Record '
Form 4
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 ho determine the form they use' The System Pumping Record must baeubmi�edto
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information �
Important:When �
filling out forms 1. System Location:
on the computer, /r ��m�~�°�~ '
use only the tab [ \^� .
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key m move your -~~^^ '-----'---'------�q�� �-� ( ~ �+--------------
oumo,-donm n~' �
use the return North Andover ---------'--- ------ - -'--- � nOYER
^«p/mm/key. S�� v~ Zip Code
2. System Owner: - &
Name ���-------'--'-- --'-'-----------
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Address(if different from m<----------------- |
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City/Town ���---�----'----- '-' ---------------- -
-- -_.
B. Pumping Rec"ord
1. Date ofPumping Date 2. Quantity Pumped: Gallons 3. Type ofsystem: El Ka Septic Tank El Tight Tank Fl Grease Trap
El Other(describe): .........
__ -
4. Effluent Tee Filter present? Fj Yes 0 No |f yes, was itcleaned? El Yes r_1 No
5� Condition ofSystem:
��� ----
6. System Pumped
momo � ��------'-' --------'-----------
Vehicle License Number �-
Stewart' Septic
Company ----'---- -- '- �
7. Location where contents were disposed:
Stmwarfs Pre-treatment Plant, 20 So Mill_Bradford,_MO18y35
S�name of Havler -------'-----' --------'--' ----'--
SignamnaufReoeivingFaci|ty ----- -'- --'-- Date-----'---'-- ---
t5fm��c-03/06 System Pumping Record -Page 1 of 1