HomeMy WebLinkAboutSeptic Pumping Slip - 30 OXBOW CIRCLE 5/10/2016 Commonwealth Of Massachusetts
City/I own Of North Andover �
System Pumping Record
OIL
DEP has provided this form for use b local Boards of ;feal , �� 4�toe used, but the
information must be substantially the same as that provided here. Be'ore this form, check v,
local Board of Health to determine the form they use. The System Pumping Record must be subs
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 Wormation
Impor`Rant:When
Suing out forms 1. System Location:
on the computer, M p
use only'he tab f
key to move your Address —
cursor-do not North Andover -"' ---
use'he return
key. C'iy/Town ---- _._.........
State, Zip Code
2. System Owner:
-----_-------
—
Address(if d'fferent from location)
City/T own _...,. ..,_ .. _.. -...._.._,.__._._......_,_. _
State Zip Code
Telephone Number _
B. Pumping Record
Date 2. Quantity Pumped: Gallons
1, Date of Pumping C'......_ ..... .. C$
3. Type of system: ❑ Cesspool(s) Septic Tank Ti ht Tank
❑ g ❑ Grease Tr
❑ Other(describe): -.------.
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes/& No
5. Condition of System:
f
6, System Pumped By:
r
t y. L, pse�N tuber
Name --------"—._,... __ _'-�°� y✓°`' __
— -
Stewart's Septic Service Vehicle en
Company _ ..,_.....
7. Location where contents wer dis sed:
Stewar�11s r men ant 0 So, Mill Bradford, Ma 01835
Signature�
of auler
Date ,. ------
Signature of Receiving Facility _
Date
t5form4.doc`03/06
Svstem Pumping Record-Page