HomeMy WebLinkAboutSeptic Pumping Slip - 336 SHARPNERS POND ROAD 1/19/2016 /`{}mRl[)[lyVea|fh of Massachusetts ]A j 1 \ 70yH
City
[Town' - '' M of TO�U�FM�"{/,ANDOVB�
System Pumping Record NORTH ANDOVER
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Form
- DEP has provided this form for use by local Boards of Health. Other forms may Ua used, but the
information must be substantially the same as that provided here. Before using this hann, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to |
the local Board of Health or other approving authority within 14 days from the pumping dote in
accordance with 31UCK4F715.3S1 �
A. Facility information
Important: �
When filling out System Location.-
forms onthe
computer.use <//^�'-'� �
only key «««
m move your
000w do not mm� Zip Code
�e*e��� '
x;v 2- System Owner:
wan ~
Tcf-dr-es'-s(1-f-d-ifferent from location)
_- _
-- - - Zip Code
Te—lephone Number
B. Pumping Record
1. Date of Pumping Dat*e 2. Quantity Pumped:
3. Type ofsystem: Cesspool(s) icTank Tight Tank El Grease Trap �
Fl 0ther(denchbe)�
4. Effluent Tae Filter present? L_Q~/{ijs E] No If yes, was it cleaned? [] No
5. Condition ofSystom-
6. System Pumped By:
Wind River Environtncuta)
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_-~'___-__ 0N930
. �
Company
T Location where contents were disposed:
-
omo
Signalure m Receiving Facility Date
/ofo'nw.o*^nzwo System pum»'"y Record'Page / of` �