HomeMy WebLinkAboutSeptic Pumping Slip - 50 STONECLEAVE ROAD 1/11/2016 ^ ^
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Commonwealth nfKHa,,� achusetts
City/Town uf North Andover
System Pumping '
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DEP has provided this form for use by local Boards of Health. Other forms may be used,
information must besubatandaUy the same asthat provided here. Before using this form, check with your
local Board nf Health tu determine the form they use. The System Pumping Record m ` beaubmiModto
the local Bound of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CK4R 15.351. " --
A. Facility ....~....~~^"="" �
\mPn` nt:When
filling out forms 1. System Location:
on the computer, r��0 TOY��0FH���U�NDLNER
use only the tau
�9mmmeyour Address � —^�`�----- -----' - ----------------
oumo,-uonot
use the return North Andover
_________�__ ___�_ _�.. _
key. ~�''~~'' State Zip Code ----
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2. System Owner: &
Name
8ddrens(if diffenanthnr�|o ion ----''------'--'------'----------------- - |
City/Town ��--------�--' --' ---------------- —
�
Tel�ph*na wvmber�-----'--
B. Pumping Record
'
2_7-1:S'
1. Date ofPum�ng --- 2. Quantity Pumped: ---
Date Gallons
3. Type of system: El Cesspool(s) Septic Tank Tight Tank El Grease Trap
LJOther(describe): -------'------` '--______----__ '-'----- --
4. Effluent Tee Filter present? Fl Yes E] No If yes, was it cleaned? El Yes M No
5. Condition of System:
�-_-_-_'_-___-__-_-----_---_-__
h. 8ymham Pumped By:
ma�e ��--------- --'------''---'-------
Vehicle License Number ��--'----'
Stewart's Septic Service
Company ----- --- '-
7. Location where contents were disposed:
Stewart'p Pre-treatment Plant, 20 So Mill_Bradford,_Nt_01835
o,gnam�uf �
nau ,
� ------'----'- --------''-'' ' -----
oa� �---------
ognat",*«[geoeWving —'�---' ---- - ----
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mmnm4.uuc-03/06
System Pumping Record'Page 1of1