HomeMy WebLinkAboutSeptic Pumping Slip - 193 LACY STREET 5/2/2016 Commonwealth of Massachusetts
- u pity/T®wry of NORTH ANDOVER g MASSACHUSETTS
_ -
System u In Record
Form
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the 193 LACY ST
computer,use
only the tab key Address
to move your N.ANDOVER MA 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
rab SCOTT STANNARD
Name
Address(if different from location)
City/Town State Zip Code
617-957-8327
Telephone Number
B. Pumping ecord
05/02/16
M
1. Date of Pumping Date 2. Quantity Pumped: Gau n-- s
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pu axal By: ✓
Name Vehicle License Number
SOUCY SEWER SERVICE INC
Company
7. Location where contents were disposed:
G.L.S.D.
5/02/16 _
Signat a of Hauler Date
http://www.mass.gov/dep/water/approvals/t rms.htm#inspect
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