HomeMy WebLinkAboutSeptic Pumping Slip - 26 TURTLE LANE 5/12/2016 Commonwealth Of Massachusetts
CityF1 own Of Nbrs h Andover
°(:"WPB CT
° .system Pumpng Record
b=oa-m 4
DEP has provided this form for use by local Boards of I leakih, 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 sL
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 Wormation —
Important:When
filling out Torms 1. System Location:
on the computer,
use only'he tab
key to move your Address
cursor-do not
use the return North Andover
key. C'riy/Town ....... .
Sae•. Zip Code
2. System Owner;
Name --
Address(itdB"erentfrom location)
State Z-ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ! �u�
Date --
- -" ----. . . 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) 3/Septic Tank ❑ Tight Tank ❑ Grease
❑ Other(describe): ---___:....;...._n..... __..._.._.._..__-_,__._._.._.... .. .
4. Effluent Tee Filter present? ❑ Yes ❑ No 11"yes, was it cleaned?
Yes N(
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Stewart's Septic Service
Company —._._.....
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature o,Hauler
_.
- Date
Signature of Receiving Facility
Date
t5form4.doc•03/06
Svstem Pumping Record-P�