HomeMy WebLinkAboutSeptic Pumping Slip - 1030 JOHNSON STREET 3/2/2016 Commonwealth of Ma sachusetts
FMCEIVED
City/Fown Of North Andover
.System Pumping Record TOWN 01 At4 DOVER
.
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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 submi-Li
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 lnfo radon
Important:When
filling out forms 1. System Location:
on'the corn uter,
use only the tab
key to move your Address
cursor-do not North Andover
the return
key. City/Town
State Zip Code
2" System Owner:
4
Name _..... .......__ _._-__.___..----_.-------
Address(if different from location)"—
City I own _.. - -.-_..__._.—........._.. _
State Zip Code
" Telephone Number
B. Pumping Record
1" Date of Pumping Date �wrt "
_---- _...... ........... 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
El Grease Tray
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: �
6. System Pumped By:
—A�_ q
Name
—
Stewart's Septic Service Vehicle License Number
Company _.._.—..._..... ......._ .
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler — "---" "__---
.
Signature of Receiving Facility
Date
t5form4"doc•03/06
System Pumping Record-Page