HomeMy WebLinkAboutSeptic Pumping Slip - 1077 OSGOOD STREET 2/9/2016 ^ ' ^
^
. �
Commonwealth nfMa,� arhu
City/Town of N )r|h Andover
System Pumping Record '
Form ^»
DEp has provided this form for use by local Boa,ds of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, oheckvi
local Board of Health to determine the form they use, The System Pumping Record must beaubm
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 153�1
� .
A. y Information
Important:When `
filling out ionno 1 System Location:
�
no�mcomPv�� ' -
use only the tab
key to move your Address
curso 'unm*
use the return North Andover
-__-- ----- -----------''--
*=' ^�//o°n S:�e ��cogn
� � � � �
2. System Owner: �
Name ���------~��y-'--- -- ------'-------'-----------------
Add�aa(�dm�=nt�ommou�nn)
—
--- -''- -- -' --- ---------------'------------' �
City/T own ���----------'--� - - � ------------ .......... -
Telephone Number
1
Date of Pumping ���-//��- 2� Quantity Pumped-
Date Gallons 3. Type nfsystem: Cesspool(s) El Septic Tank E7 7lghtTank
L�
Other(describe): -----'--- ....... -`-�---------------' ......
4� Effluent Tee Filter present? Yes F� No If yes, was itcl'eaned? F� Yes F� No
b. Condition of
------------'...... .............
__-________
. _'-
Name ��-�---------- - ----'---- -------
~�'~ vehicleLicense Number
Company ------ --- '-
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill_Bradford, Ma 01835 _______________________
signature of Hauler -----------''--- --------''-'' '-----
� Date
olgnom�ov�eceiving m
F� -' ' --- - - - -' -'---- ---- - ------------
=� Date
k5=nn4.dmc-03m6
. xxmern Pumping Record'Page