HomeMy WebLinkAboutSeptic Pumping Slip - 109 RALEIGH TAVERN LANE 1/14/2016 j
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System Owner System location
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Date of Pumping: Quai►tity Pumped:���� gallons
Cesspool: No �~m Yes Septic Wank: No IJ Yes
System 1'Y1n►ped by: vtlecdart 050Arvqma license#
Conlews iransierrred to : �re�ter l.�wre►tee t3�nit�ry IUis�tricl
Date: _.� __ Inspector:
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HEALTH
PA6E 0 222�
COInITIO!Iwealth Of Massachusetts
0P City/Town of NORTH ANDOVER MASSACHU E :I.S:RECEIVED
5A,
System Pumping Record
FOrm 4
OCT 16 2006
DEP haS Provided this form for Use by local Boards Of Health. The Sy 9 0 rn VER
be submitted to the 10CHI Goard of Health or other approving authority.1 t HE 'rH T
X Facility Inforri—nat—ion
Important
When filling out 1. System Locatioll:
forWis on the t
computer,ijsc-
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only the tab koy lav
to move your pp O.W,q .-do Ilot
use tile return U n
key, $04te L;,()Cle
2, -8y t 0 vner:
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Name
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-t !P 110110 Number
E3- PUMPing Record
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I- Date of Pumpjqq DWIn 2, uanfity Pumped:
e gibs
3- -FyPe Of system: El cesspool(a)
�Zootic Tank ❑ Tight TariK
❑ Other(describe):
4. Effluent Tee Filter present? Ej Yes ❑ No
5, Condillon of Systepj, it yes was it Cleaned? yes I❑ No
6, System PuMped Sy;
N
0 1 ITIP any ehicl
7. Location where C.011terits were disposed:
Sign I[,,ro
of Hau-r
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System PumPiilg Record,Pagr=1 of 1