HomeMy WebLinkAboutSeptic Pumping Slip - 315 SOUTH BRADFORD STREET 1/1/2011 Commonwealth of Massachusetts
City/Town of
System PLImping Record NORTH ANDOVER
Form d
DEP has provided this farm for use by local Boards of Health,Other forms may be used,but t
information must be substantially the same as that provided here.Before using this form,Che k withif,r,°
local Board of Health to determine the m they use.The System days Pumping Record Pumping dabeeis Ubmitled tCi'
Y
the local Board of Health or other dq
accordance with 310 CMf2 15.351. l i J1 (
A.
. Facility inforrnation
IropoAanit i�rP A„(V`DJ,}`l,I.,{
forms on the
out 1. System Location'. ,1, t.. r
loans on the �)1 'S- h 1
computer,use __ f
Address) z r II q
only the lab Rey —✓4✓07 4L r ct o e f te � Zip code
to move your -- Stale z"p�r>de
cursor-do not CityrTawn
use the relurn
Rey. 2. System owner:
�3!"\p1 -4 G _R�ht, —... .__ _, -
Name _
rwn Address(If different Bam local on)
- — State
Telephone Number
B. Pumping Record ItaD�
2 Quantity Pumped. Gauans
1 Date of Pumping Date
3. Type of system ❑ Cesspool(s) arSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ other(describe)
4, Effluent Tee Filter present? ❑ yes No if yes,was it cleaned? ❑ Yes A�)No
5. Condition of System:
6 System Pumped By
Vehicle Llaense Number
Name i
Company
7. Location where contents were disposed:
No*AmdWa bale
5rgnatura al Hauler
Date
Signalule of fteceivtng Fac+liiy'
system Pumping Record•Page I Of I
WomW.doa 05+08
L-\ Commonwealth of MassachLlsetts F—� � ` r
t? City/Town of r
System Pumping Record NORTH ANDOVER
Form 4
DEP has provided this form for use by local Boards of Health.Other forms may be use but the
information must be substantially the same as that provided here.Before using this for
local Board of Health to determine the form they use.The System Pumping Record m st b e66601.410f,",t rrt Q e ( I 1 d
the local Board of Health or other approving authority within 14 days from the pumping
accordance with 310 CMR 15.351
A Facilit-y Information
Important:
When ruling an 1 System Location
forms on Ino
comp At ustr
only the lat)key Addwss
lo rr}rave Gaut
Ctlrsnr ao rrol �,' •�'.)t',f "� 1
Usr9(hkr Y41UIn
v4yfTowr :nlnle lqA (A(.1
key n
,, System Owner
�"'�"�....... Adtlfoss id differenl from Ior.rrtion)
yTasrrr til�al kr„� 'a. Zip(;