HomeMy WebLinkAboutSeptic Pumping Slip - 29 PADDOCK LANE 5/12/2016 Commonwealth of Ma,,�sachusetts
City/Town Of North Andover of,
System Pumping record TOWN
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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