HomeMy WebLinkAboutSeptic Pumping Slip - 350 HOLT ROAD 2/9/2016 � Commonwealth nf88B � achusetts
City/Town of N }, L6 Andover
System Pumping� � Rec��rd '
`
Fmr0m4
DEP has provided this form for use by local Boards ol Health, Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with �
local Board of Health to determine the form they use. The System Pumping Record must be submitie
the |om*| Board of Health o[other approving authority within 14 days from the pumping date in
accordance with 31OCMR15,351.
'
A. Facility -''_-...~~~.~^.
Important:When
filling out�nns 1. Location:
un the computer,use oni 'the tab
��
key xu� �
a � -----' -------�+�'n�c» n��2�T----------
cursor'uwnot
use the return ''-'~' '^~~`~ --_-- ----_- �
key, u�'/vw» state Zip Code
2. System Owner: �
Name ~- � - n--- - -�' '---------'----------------------'
�-�--
Address(if different from location)--- - -'-- -' '- -- ----'---------'-'--
CityrFown ����----- '-- '--- -� State------------ Zip
����' ������_ ���
B. Pumping Record
Te�phonewvmho,
1 Date of Pumping 2. Quantity Pumped: Gallons 3. Type ofsystem: F� Cesspool(s) Septic Tank El Tight Tank [I Grease Trap
LJ Other(describe): --------------,'�-----'--------'._-__--
4. Effluent Tee Filter present? E] Yes No If yes, was Kcleaned? F-1 Yes F� No
b. Condition ofSystem:
6. -"'-yotem Pumped 8y:
wume �--�---''----- -- -----'--- ------
Vehicle License Number
Stewart' Septic
Company �----- --' '-
7 Location where contents were disposed,
S8ewert'n Pre-treatment Plant, 2U So. MU _8naUbrd^_MoO1835_________________________
Signature of Hauler --------'----- --------''-'' ------------'----'
� uate
G�^om�oeceimng �x�, '-'-- - ' -�--' �D-a te---- ---- ' ------------
k5fm���03/06 System Pumping Record-Page I o