HomeMy WebLinkAboutSeptic Pumping Slip - 16 OGUNQUIT ROAD 12/8/2015 -
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Commonwealth nfMa � sachuseft '
City/Town of North d
CVer
Syst m Pumping Record '
Form 4
DBP has provided this form for use by local Boards of Health. Other forms may beuaed but the
information must besubstanhaUythe same aothat 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 310 CyNR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer.
use only the tab
key to move your Address -` / ~ ' -�-��---'-~---���---------''-----'---' - -------------------
uumu,-uunm
North Andover
use�o�m� ------- ' - -------------- -----------------
key. ~'v''"=' State Zip Code ��--
2. System Owner: � &
Name
Address(if different from location)
---'---- --- --'---------'---------'-----
C�y�own ���------------ --' ---------------
--
�pcouu �
B. Pumping Record
1. Date ofPumping - 2. Quantity Pumped: 'ballons
Date
3. Type of system: F� Cesspool(s) Septic Tank F] Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? F] Yes E] No If yes, was bcleaned? Yes F� No
5. Condition VfSystem:
h. System Pumped By-
Name ------ --'--------'----------- �
w / vooio|e���naewu�ba, � ��----
Sh*wart'e Septic Service
Company �-------- -- '—
7. Location where contents were disposed:
Stawort's Pre-treatment Plant, 20 So. yWiU Bradford, Ma 01835
Signature ofHauler ��-------------' --'------'--' ------Da
��nom�pfRaoaiwnQ =am� ----- -- ---- ����-----' - .......
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