Loading...
HomeMy WebLinkAboutSeptic Pumping Slip - 29 PADDOCK LANE 5/12/2016 Commonwealth of Ma,,�sachusetts City/Town Of North Andover of, System Pumping record TOWN ` `T Foam.4t Lit 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 wit local Board of Health to determine the form they use. The System Pumping Record must be submi the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. �. Facility Mormation Important:When fining out forms 1. System Location: on the computer, f �*use only the tab ' s do- keyto move your Address ---- - -.--- cursor-do not North Andover use the return key. City/Town ------..._.._........ . State , Zip Code — 2. System Owner: Address(if different from location) — State Zip Code Telephone Number " __.._.. B. Pumping Record 1. Date of Pumping date - Quantity Pumped: —_ Gallons 3. Type of system: ❑ Cesspool(s) ml&ptic Tank ❑ Tight Tank El Grease Tra ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ "es ❑ No 5. Condition of System: n� 6 System Pu ._ 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 Signature of Hauler --- Date Signature of Receiving Facility Date - tSfomr4.doc•03/06 System Pumping Record-Page 1