HomeMy WebLinkAboutSeptic Pumping Slip - 35 SHANNON LANE 11/16/2015 - ^ ^
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Commonwealth of Ma_&,sachusetts
City/Town of North Andover
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System Pu00�~�� Record '
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Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be uoed, 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 local Board of Health or other approving authority within 14 days from the pumping date in �
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accordance with 310 CN1R 15.351.
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A. Facility I����00�������
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Important:When 1. System Location:
filling out forms on the computer,
use only the tab
key to move your Address
cursor do not North Andover \�'^``'-
vaemo�tvm ------_____'-_ ---'--.. _ '_'_--_--_-'-_' -------------'---
�y. C.o,/m°o State Zip Code
2. System Owner: &
Name " ' � ��'- ----- --' -'--'--------------------------------
-------
Address(if different from locatio�)'---'-- -- -- -- --- --'------------------------------
CityfT"wn ��------- '------ -- ' ��ate'--------'--_ Zi--Code---------- �
T*|opxonew�mber
BB Pumping Record
. . ~~ . `~ .~. �
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1- Date mfPumping 2. Quantity Pumped: ' --Gallons 3. Type ofsystem: Fl Cesspool(s) Septic Tank F Tight Tank El Grease Trap
F7 Other : _'--_-_ _-
4� Effluent Tee Filter present? [� Yes [:1 No If yes, was it cleaned? D Yes [_1 No
5. Condition of8yshem:
- System ' —'r-~ ~y:
woma / ����-------- --'-----''--- -------
Vehicle License Number
/
Stewmff s Septic
Company ' ��------- -- '—
7. Location where contents were disposed:
btewa/to Pre-treatment Plant, 2U So. Mill Bradford, Mo0183G _____________
Signature ofHauler � ------------' --------'-- ---'--Date
Qona��vfReuei'vin0ram------- - ---- ----- '---- - ' ---
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t5fom4.umc-03m6
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