HomeMy WebLinkAboutSeptic Pumping Slip - 112 TUCKER FARM ROAD 5/29/2016 Commonwealth Of Massachusetts
❑lity/Town of North Andover
Pec
System PqAmp�ng Record
DEP has provided this form for use by local Boards of Health. Otfi 249 ti'$p„ Xf9 e used, but the
information must be substantially the same as that provided here. � f check wi
local Board of Health to determine the form they use. The System Pumping Reco41 be subm
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 wormatio n
Important:When
fining out forms 1. System Location:
on the computer,
use only the tab /1 -- / lO C/L/ r
key to move your Address ---_._._......_..___..._.___.__. ...--.._--_...-•----._-... .
cursor-do not
use the North Andover
key, -— _
e return
City/Town
y State - Zip Code
2. System Owner:
044 U01
Name
-
Address(if different from location_)_ .,_...._.. ._._.---..--•--------...__.-.-------,_—--
City/T own _... - —.—.......__..
State Zip Code
_ Telephone Number _..-.-_-•--•
B. Pumping Record
1. Date of g
Pum in _
p 2. Quantity Pumped. n
Gallons
3, Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Try
❑ Other(describe): - -.......__..._..._.. ...... ._ .
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name ------------- - .. _ .._. .�-- -------
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
SignatureofHauler —.__.._....__.....___-_-._ _
Date
Signature of Receiving Facilry '"
Date -
t5form-',.doc•03/06
System Pumping Record-Page