HomeMy WebLinkAboutSeptic Pumping Slip - 259 CAMPBELL ROAD 1/11/2016 - -
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� Commonwealth of Ma � sachusettc
C' nfNorth Andover
System Pu00p^ng Record '
Form 4
DEP has provided this form for use by local Boards of
Health. Other forms may be used, but the
Before using this fo'form, check
w�hlocal Board of Health to determine the form they use. The System Pumping Record must"beaubmi ue the local Board of Health or other approving authority within 14 days fnom the pumping date in
accordance with 310 C&R 15.351.
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A. Facility ^"""~~"""ocou,00n
Important:When
5Ui»Q out forms 1. System Location:
onmecompv��
use only the tab 2��
key to move your Address � ---'-��� T���r��z�~ ' ---------------
ourso -uonm ' --
use the return NorthAndover
key. uty/rown
State ~p~"""
2. System Owner: �
Name / -- -----' - -'------------------
*dureaa Cif—different fmr��nv�on --------- -' '-- --'--'-------------------------
o�n��n ---------'-- -- ' ' ----'-----------__ _
Telephone Number
B. Pumping Record �
1. Date ofPumping 2� Quantity Pumped: Gallons 3. Type ofsystem: D |kd Septic Tank E7 Tight Tank F7 Grease Trap
,
�l
Other : --_-_'__'_---` '�--------------'-------
4. Effluent Tee Filter present? FYes F� No If Yes, was*
it clean-ad? El Yes FjNo
h. Condition ofSystem:
����� ���
. -y~~~ ^ Pumped By:
�
Stewart's Septic Service Vehicle License Number �---
Company ------' --- '-
/. Location where contents were disposed:
-_..`~ Pre-treatment Plant, zu So. Mill Bradford, Ma01 %35_____________
��nam�v*��v�r --�'--------- —'---__'--' -_--_
��name«rRece*ngroo�y --- - - -�-' -'�--- - '--- - -__
ua ----------
t5mnn4.uwc-03/06
Symem Pumping Record'Page 1 o