HomeMy WebLinkAboutSEPTIC PUMPING SLIP (4) �\ Commonwealth nfMassachusetts �
City/Town
System Pumping ReGord NORTH ANDOVER
Form
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information must bonubmtontioU e-
substantially that provided here. Before using this form, check with your
local Board ofto determine the form they use. The System Pumping Record mu��hosubmd�dW
the local Board Health HeaKh or other approving authority within 14 days from the pumping dote in
accordance with 31OCKXR15351, �
A. Facility information
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Important:
When filling out System Locahon�
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computer,use _����_/_/r�r�C��~ ^/ ' ~� �`�/-- -- -----'-- - - - '
only the tab key ««
mmo^cyow/ Stale Zip Code
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key. 2 System Owner:
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Name
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B. Pumping Record
or
1 Date of Pumping Date 2. Quantity Pumped: ons
3. Type o(system: Ej Cesspool(s) Septic Tank Tight Tank F] Grease Trap
Fl Other(describe): ( u +'~ - -
4. Effluent Tae Filter present? Yee ANo if yes, was it cleaned? Fl Yes [] No
5. Condition fSystem:
& System Pumped By: �
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Wind River Environmental
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Company |
7 Location where contents were disposed:
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