HomeMy WebLinkAboutSeptic Pumping Slip - 59 PENNI LANE 3/11/2016 ^ |
� Commonwealth `of &/la_,� ach0sett . RECEIVED ' |
C'H"V/ ] 8n of North Andover &D� 1 1 9O1�
Stem Pu00�-�� ������� '
~ ` «-^ ~" " �� » "� �OWJ OFND�R4ANOOVER
Form � [E�R ���
DEP has provided this form for use by local Boards cfHealth.'O^the/forms may beused, but the
information must be substantially the same as that provided here. Before using 'this form, check
with
h|uca/ BuardofHea|thtodeterminetheformtheyuae' The System Pumping Record must oeou b i_U the |noa/ Board of Health or other approving authority within ' days from the pumping date in a000rdancevi1h 310 C&R 15.351. �/
`
A. Facility ovoxoouoocxuoon
Important-When
miingmutfonnn 1 System Location:
vv the computer,
use onlythe tab
�y'tomovayour Address --------___ '-__.---_-' - ------------'
cursor do not
« North~"' A
key. c�,ioown _--------- ------* ,,
----_'_- _
2. ��neOwner, Zip Code �
mame ` ---- ----- -- -'--'--------__
.--~^--�
�ooeau(*ua��n m`m�oa*nn) ------ — -' -- ----'----------'
Inwn �----------------� -- ---'-----_-_--__ --
Pumpi Telephone Number
1 Date of Pumping ----��-' - 2. Quantity Pumped:
Date Gallons
3. Type ofsystem: E7 Cesspool(s) Septic Tank D TightTank E7 Grease Trap
FlOther(describe): ------___~----,'�---- -------------------------' |
4. Effluent Tee Filter present? F7 Yee �� �o � �
�� �� yes, �� Yea �� No
5. Condition ofSystem: ,
b- �
n�/�' > |
���"�� �
G� System Pumped By:
.,~..=
Stewart's Septic Service Vehicle License Number
Company ---- --- '-
/ Location where contents were diaposed�
Ste wart's _Bradford,_MuO1835_______________
Signature«rHauler —'------'--- . --
Date
�enamreor�aceiu"er�c �» '--- ' -� --- -----' -__
Date ------------
ommw�oc-03/06
uYS'Lem Pumping Record'Page I