HomeMy WebLinkAboutSeptic Pumping Slip - 34 BOXFORD STREET 1/19/2016 �
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d\ Commonwealth of Massachusetts �
City/Town rf �
System Pumping Record NORTH ANDOVER
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Form 4
--'- DEp has provided this form for use by local Boards «f Health. Other forms may beused,
but the
information mun\benubutanbuUythenamoasMhatpnov ide dne ne, Beforouaingthinh».. . check
with your
|u cm Board of Health to determine the form they use.The System Pumping Record must ba submitted to
the local Boa rd of Health or other approving authority within 14 days from the pumping do10 in
accordance with 31OCK8R16361, |
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A. Facility information
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important:
1 Location:
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forms on the
oomnum�mo
� the�bkey Address_ '�K1 � , `�� qc�
to move your /�D[������ -' -' -/�� y� � `�'~ ���� ��--
cursor do not "^~^- - State ��--� /w�^vo
use the return City/Town
»c' 2. System Owner.-
T
Tddres(IJ(different from location)
---- -- - ' -- s�� Zip Code
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Telephone Number __
B. Pumping Record
1. Date of Pumping 2. Quantity Pumpedi Gallons
Date
3. Type ofsyoteyn� El CesspooKs Tank Tight Tank F] Grease Trap
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4. Effluent Tee Filter present? [] Yes -' (f yes, was kcleaned? E] Yes [] No �
5, Condition ofSyntem-
G. System Pumped By.
Wind River
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Name
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7. Location where contents were disposed:
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