HomeMy WebLinkAboutSeptic Pumping Slip - 356 RALEIGH TAVERN LANE 5/12/2016 ❑e�rrer onwealth of Massachusetts
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System Pumping Record Mt'Jl�f,l I'f ICP=dl,�a1IL:C
Form L1vJ'
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 v,
local Board of Health to determine the form they use. The System Pumping Record must be subn
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351,
A_ FacHilty Wormation
Important:When
filling out forms 1. System Location:
on the computer,
use only the tabj(
key to move your Address ---=} _ ....._..___.�.!✓_�_.®_! /.__.._---. ---.---....
cursor-do not
use the return North Andover
key. C'rty/Town
State, Zip Code
2. System Owner;
Name _.....__ .._.... .. ......__._
Address(if different from location)
CityfTown _.......... ..
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - --- _ Lp rr''
Date 2 Quantify Pumped; - U —
Gallons
3. Type of system: ❑ Cesspool(s)
X Se tic Tank p Tight Tan c ❑ Grease i r
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No IT yes, was it cleaned? ❑ Yes
� ❑ No
5. Condition of System:
P
6. System Pumped By
Name — — Vehicle License Number
Stewart's Septic Service
Gampany ._._..._..... ......_ .
7. Location where contents were disposed,
Stewari's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler —..____....__.....____....
Date
Signature of Receivi ng Faciliy
Date
t5`om4.doc•03/06
System Pumping Record-Page