HomeMy WebLinkAboutSeptic Pumping Slip - 520 FOSTER STREET 1/11/2016 -
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Commonwealth of Ma,-� achusef s
City/Town of NJrfh Andover
System Pump^n� Record '
Form -
[EP has provided this form for use by local Boards of Health. Other forms may beu� ��
informahonmust beoubu�ndu|k/the same eo that provided here. Before using this fo-- check w�hyour
�oa| Board ofHeo�hho determine the form they use. The System Pumping Record m''` beaubm�edto
the |ooe| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CK4R 15.35 � --
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A. Facility Information
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filling out forms 1 System NOFNORJNANDDVER
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on the computer — DE�RN�T
use only the tab
key m move your xuueas ���--------------'-----'---' � ------------------
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use the return '`~'"' Andover ----- ------- -------
key. City/Town 8tate ----''--- —Zip Code
2. System Owner
mama ' ----' -- ---------- ------------
9ddreon(if—different frxn iw ---------'- - '----''-'----------'-----
C�yn»�n �------'----- - ' ----'---------'--' - |
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B. Pumping Record
1- Date ofPumping ���'�������'-��'_ 2� OuanU� �umped� ---Gallons 3. Type ofsystem: El bd Septic Tank [l Tight Tank Grease Trap
E� Other(describe).- ---------------��--________-_........
-'---- --
4. Effluent Tee Filter present? F-1 Yes No If yes, was it cleaned? Yes No
b. Condition of System:
b. System Pumped By-
Vehicle uc~noewumuc, -----
Stewaff s Septic Service
Company ------ -'- '-
7. Location where contents were disposed:
"=",a.t's Pre-treatment Plant, 20 bn [N8| Bradford, Ma 01836
oIgnotumof Receiving -- - -- - '-'-- -'------ --- ' -----------
Facility Date ----
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System Pumping Record-Page 1 of