HomeMy WebLinkAboutSeptic Pumping Slip - 57 CHRISTIAN WAY 11/16/2015 ^
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Commonwealth` ' nfMa,-� achu
/�' nf �J� �� Andover
City/Town[y0�� ��/ North ^^�l.�over
System Pumping Rec ord '
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DEP has provided this form for use by local Boards of Health. Other forms may be uaed, but the
information must be substantially the same an that provided here, Before using this form, check with your
local Board of Health tn determine the form they use. The System Pumping Record must be submitted hn
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCK8R 15,351.
A. Facility Information
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Important:When
filling out forms 1. Svabam Location:
mn the computer, N0U 1 A ��1�
�eon��e�b - -- ---------!�� ��w`'--- �
key to move your Address � ER
cursor do not
North Andover
use the emm ----- -----'- '
key. `�w/uwn St e Zip Code
2. System Owner: �
Name `~ - � --------'-----'-------------------
--�
Address(if different from location)
------ -- ------'--------
Cdy�own ��----------------'-- -' S�te'----------- Zip Code |
B. Pumping Record ��������������'
Te�pnoneNumh*,
1. Date of Pumping 2 Quantity Pumped: ---�����~�------
oo� � � 6o||ona
3. Type of system: U Cesspool(s) Septic Tank F-1 TigNTank El Grease Trap
LJ Other(describe): --------'-----------'-------------'------ __
4. Effluent Tee Filter present? F] Yes 0 No If yes, was it cleaned? F Yes F-1 No
5. Condition ofSystem:
- System— P-^'r` |
/
Name ---------'---------
Vehicle License Number
Stewart' Septic Service '
Company ���---'-- -''-- '—
7. Location where contents were disposed:
8hywarCa Pre-treatment Plant, 20 So. Mill Bradford, PNa01835 �
Signature ofHauler ���-----''-- ' ------ --
Signature of Receiving Facility ----- -- '----' �Date----' -----'-- ---
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