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HomeMy WebLinkAboutSeptic Pumping Slip - 30 LACY STREET 1/11/2016 - ' ' ^ ^ � ^ � ' 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 � 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: —-���������������������� ���'����������� 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« --- - ' -�-' -'---- ----'-' --_ --` uate z5lvnn4.um/03m6 System Pumping Record`Page 1 of