HomeMy WebLinkAboutSeptic Pumping Slip - 10 OLYMPIC LANE 2/9/2016 Commonwealth m� K�Massachusetts
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City/Town of North Andover
over
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health, Other forms may bo uoed, but the
information must be substantially the same as that provided here. Before using this form, check with your
|noo| 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 deb» in
accordance with 31UC[W � �R 15 3�1 [-
A. Facility Information
Important:When |
filling out forms 1. System Location:
nn the computer,
use only the tab 10 01(mic Lane
key m move your *ugmon ^
cursor-do- North Andover MA uso m mm
the
key. City/Town State Zip Code
2. System Owner:
^-----~ Gorbet
Name
Address(if different from location)
City/Town State Zip Code {
Telephone Number
�
B. n-umunopnxng Reconuu
1. Date ofPumping Oma�� Pum��� �
uo�' — Pumped: Gallons
3. Type ofsystem: F1 Cesspool(s) [/Septic Tank El Tight Tank El Grease Trap /
El Other(describe):
4. Effluent Tee Filter present? DYes No |f yes, was dcleaned? F-1 Yes 0 No
5. Condition of System:
O. System Pumped By:
Name Vehicle License Number
�
�
Sbawart's Go �
Company
7� Location where contents were disposed: �
Stewart's,PreAreqtment Plant, 20 So. Mill Bradford, Ma 01835
Date
Date
,5m,m4.doo`03/06 System Pumping Record^rago 1 of