HomeMy WebLinkAboutSeptic Pumping Slip - 81 LACONIA CIRCLE 12/8/2015 - .
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Commonwealth mfMa_,� achusetto
�~' of North Andover
City/ | [)V�y] .�/ '�[). �v / / `M`�o\fer
System Pumping Record '
Form 6i
DEP has provided this honn for use by local Boards of Health. Other forms may be uaed, but the
information must be substantially the same aethat 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
accordance with 31OCyWR15,351. �
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A. Facility Information �
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Important:When
filling out forms 1. System Location:
on the computer,
use only the tab �� ~
key 0u move your Address -----'--------''--------'' --'-----------------
oumur-uonm
North Andover
usa�em�m -- ' -' ------------- ------------'----
key. ^'`r'"w" State Zip Code
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2. System Owner: &
Name - ~~~ --- ��---�---'- ----- --�-'-------------
Auu�msV[u�e�nt�nmlocation)
----------- --'----'-'--'--------'------'-- |
Citylfvwn �--'---'--- '-' -----'-----------
_- -_.
B. Pumping Record
'
1. DahaofPumping
Date --- 2� Quantity Pumped: --'Gallons 3. Type ofsystem: Fl Cesspool(s) Septic Tank Fl Tight Tank Grease Trap
UOther(describe): -- --'--�—'----__'___- _
4. Effluent Tee Filter present? Yes No |f yes, was itcleaned? E7 Yes 0 No
5. Condition ofSystem:
b. 'System Pumped By:
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Name --'-----'----------------------------
Vehicle License Number
Stewart' Septic
Company -------- --- '-
/. Location where contents were disposed:
uo:wa/tu Pre-treatment Plant, 20 So. MU _Brodford]Na81835______________
§7tgnammofHau�r ��-------------' --'------'-- ----- �
8g^amre of geooivinoFacility -'-- -- '---- ���---- -.......- ----------------
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