HomeMy WebLinkAboutSeptic Pumping Slip - 216 FOSTER STREET 4/11/2016 Commonwealth Of Mai, saehusefts � °;, C� "„'V
F City/Town of North Andover � 4
°
system
” Pumping Record
Form mvv� 1(31 i<<IItlii��iil.,riVER
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 submiu
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 Wormat»on
Important:When
filling out r y
s 1. System Location;
use only the computer,
key to move your Address _—_.-.--......._...- --- _,..•.-
use cursor
th e return-do not
North Andover
use the
key. City/Town
y State`' Zip Code —
C 4 yy
2. System Owner;
Q:a
Address(if different from location}
own State 'Z'-p Code
B. PUMPI ' Telephone Number
1. Date of Pumping -• .�w'� ( µ' " (`�
Date.._ - 2. Quantity Pumped:
Gallons <. �Y
3. Type of system; ❑ Cesspool(s) Tank Ti ht[ 'Se tic Tank
p ❑ g ❑ Grease Tray
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If es -
y was i t cleaned. ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name ------------... -ehicle,__License "Number _
V
Stewart's Septic Service
Company _..._....,
7. Location where contents were disposed:
Stewart's Pre-treat ent Plant, 20 So. Mill Bradford, Ma 01835
Si nat re of Hauie
• Date
Signature of Receiving Facility -
Date
t5`orm4.doc•03/06
System Pumping Record-Page