HomeMy WebLinkAboutSeptic Pumping Slip - 30 LACY STREET 1/11/2016 - '
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commonwealth »fMas� achusett `
City/Town of North And
over
System Pumping� Record '
Form 4
DEP has provided this form for use by local Boards of Health.-Otherfonnsmaybeuue"d' butth
e infnnmatinnmuatbeaubsbantiaUytheeameaathatprovided here. Before using this form, check
with yo
local Board of Health to determine the form they use. The System Pumping Record must be submitted
the local Board of Health or other approving euthOrityvithin --yshnm the pumping date in a000ndencewith31OCNR16.351.
A. Facility information |
Important:When �
filling out forms 1. System Location:
on the computer, - --~` ` ~--°
use only the tab
key to move your -----------'��-] 1 ���________
cursor-domm
North use the�m� "'" Andover
---_-____�__�_' --�-' --.. 'S,
��� ^'s`'°°" ta e (|�/i������E|X- -.- ---C,-o-d e--------
2. System Owner:
mama �-------- ---- -- ----'--------------
Address(if different from �n ------'-- -- -' '-- --''-'------------- |
-_--__'-_ �
ugv/o�n -� - ----------------
State Zip Code
B. Pumping Record
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1. Date of Pumping ---�' 7 -���_ 2� Quantity Pumped: -Gallons Date 3. Type ofsystem: F7 |(s) Septic Tank Tight Tank Fl Grease Trap
ElOther : --_-_-_-_-,�----------'-----
4. Effluent Tee Filter present? RYes No |f yes, was i~cfeaned? El Yes FjNo
5. Condition ufSystem:
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6. _System �
' - � �
mam� ��--------- ---__-___-_
Vehicle License Number -- |
Stewart's Septic Service Company �--'-- '-- '-
/. Location where contents were disposed:
S"^�=.° n�~uvuunenrPlant, i| _BradfordjNa01835 �
�mnam�o*��v�, �--------- --------'--- -__'-_ �-----
mQnamremneoe�nn N« --- - ' -�-' -'---- ----'-' --_
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System Pumping Record`Page 1 of