HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 5/12/2016 (2) Commonwealth 0117 MaSsachusetts
City/ oars 07 North Andover
Pumping Record
DEP has provided this form for use by local Boards of Health. Other forms may be used, but th
information must be substantially the same as that provided here. Before using this form checl
local Board of Health to determine the form they use. The System Pumping Record must be su
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351•
A. F c9�I1 �rr,�a � r ���
� � ��"d��bErB�c`����DH"il r
Important:When
filling out;orms 1. System Location-
on'he computer, —� ❑ _,.. ..._...- - - h , ��t\I
use only'he too j
key to move your Address1
cursor-do not North Andover
-
use'he return
key. C'it, Town -- —..- -
State, Zip Code
2. System Owner:
Name .__._ .... ..
Address(if dfferent from location)
State Zio Code
Telephone Number
�. PUMPi g Record
2. Quantity Pumped;
1. Date of Pumping a /_ .I
Date _
Gallons
3. Type of system: ❑ Gesspoal(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease
❑ Other(describe);
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned?
❑ Yes ❑ N(
5. Condition of System:
6. System Pumped By:
Veh_ _ _
icle License Number
Stewar's Septic Service
Company ------_—.._._..._.... . ..,,..._ .
7. Location where contents were disposed,
St wart's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
Signature o`
Date
Signature of Receiving Pacilry
.6a,te ......_.._
tS�ormG.doc•03/Q6
Svstem Pumping Record-Pa
Commonwealth Ulf Mc^aSsach ..8setts
City/I—own Of Nbr-Lh Andover
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used but th
information must be substantially the same as that provided here. Before using this form, chec}
local Board of Health to determine the form they use. The System Pumping Record must be sG
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. FacHity Wormabon
Important:When
filling out;ours 1. System Location:
on'he computer• Lli rFePlw,1 OVER
use only'he tab r
i ((�cf df��7Ef I(kril.:!.f'lof;lPl 5P1d ---_.__._---
key to move your Address _--�- -°• -- ----_�� ._._ _ _ ___
cursor-do not
use the re'u, North Andover
rn
key. C`y!1"own
State, , Zip Code
2. System Owner:
Name
rcw,r
Address(if drt`erent from location)
.--._-_ ... .._.
. State 'Z'-i'o Code
Teleohone Number
B. PUMPing Record
Date..._ _._.. __�' k✓ /,JCS
( )
1, Date of Pumping � -
2. Quantity Pumped:
Gallons
3, Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Crease
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No !f ves, was it cleaned.
'� ❑ Yes ❑ N(
5. Condition of System:
6. System Pumped By:
_ —
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 otHauler - ---....__..- ---__.
' Date
Signature of Receiving Facil'r y
Date
t5form4.doc-03/06
Svstem Pumping Record-PS