HomeMy WebLinkAboutSeptic Pumping Slip - 466 WINTER STREET 12/8/2015 �
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Commonwealth of m a,�sarhusetts �
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City/Town of North Andover
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System Pumping Record '
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, butthe
information must be substantially the same as that provided hero. Before using this fonn, 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
accordance with 310CN1R15.361.
A. Facility Information
Important:When
filling out forms 1 System Location:
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use only the tab /
key m move your Address
cursor do not
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N h Andover
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use mvn ----------- ---'-'' - ' -----------'--- --------------'----
Cdy�o�n State zipCode
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2 System Owner:
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- -----` ---`-------------'
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Address(if different from location)------- ---'-----------------------
cayTTown State Zip Code
__________________
Ta�v»onomv�her
B. Pumping Record
1. Date of Pumping Date— 2. Quantity Pumped: Gallons
3. Type ofsystem: [l Cesspool(s) Septic Tank Fl Tight Tank 0 Grease Trap
[] Other(describe): ----'--------------'-----'-------- ......
--'---- --
4. Effluent Tee Filter present? E] Yes [l No |f yes, was itcleaned? Fl Yes No
5. Condition of System:
������'�����..... ��---
U. System Pumped
Name )r-------------- Vehicie lLicense Number----'------------------
Stewart' S i '
Company
7. Location where contents were disposed:
Stevvarƒs Pre-treatment Plant, 20 So. Mill_Bradford,_Nk 01835______________________________
Signature ofHauler ------------ Date----''-'' -'---'- --
Signature� ���e Da te-----
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