HomeMy WebLinkAboutSeptic Pumping Slip - 15 WINDKIST FARM ROAD 3/9/2016 Commonwealth of Ma,,�sachusetts RECEIVED
l City/Town Of Nbrth Andover
System Pumping Record
i JEALTH DEPARTMENT
DEP has provided this form for use by local Boards of 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 submiil
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility h1forrmatio s
Important:When
fining out forms 1. System Location:
on the computer,
use only the tab �-
M key tc move your Address
cursor- not North Andover
use the return
key, City/Town _
State Zip —
�; p, P Code
2. System Owner;
Name
Address(if different from location) —
Cityrown _
State Zip Code
Telephone Number
B. Pumping Rec'ord
1. Date of Pumping Date "" .......
2. Quantity Pumped.ed: .�
Gallons --
3. Type of system; ❑ Cesspool(s) 14 Septic Tank
❑ Tight Tank ❑ Grease Trap
❑ Other(describe); ----__....:..... _..
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
J�
6. System Pumped By;
Name —i------ -"-- - Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford_Ma 01835
Signature of Hauler ——,--°
Date
Signature of Receiving Facility
16a1 te ._...._.._. __
t5form4.doc-03/06
System Pumping Record-Page 1