HomeMy WebLinkAboutSeptic Pumping Slip - 400 SHARPNERS POND ROAD 6/17/2016 Commonwealth of Massachusetts
W City/Town of NORTH ANDOVER
System Pumping Record
Form
DEP has provided this form for use by local Boards of Health. Other forms may be used,'bu"t the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
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 Information
Important:When
filling out forms 1. System Location: - 1
on the computer, ...-- -- -c,4 -
use only the tabs. < ) YYY
key to move your Address - - -
cursor-do not NORTH ANDOVER Ma
use the return - -- - - -- ---
key. City/Town State Zip Cade
f�
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
---- --- ----
Telephone Number
B. Pumping c r
1. Date of Pumping Date — 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank El Grease Trap
ly
❑ 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 p o Mill Bradford,dford, Ma 01835
Signature of Hauler Date
- -- - -
Signakure of Receiving Facility "` Doke
t5form4.doc•03/06
System Pumping Record•Page 1 of 1
Commonw llth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
System i n g Record
Form 4
DEP has provided this form for use by local Boards o Weal h.l " s Pum Ing Record must
be submitted to the local Board of Wealth or other ap roving author(ty ['H
XIN I"A.. Facility Information
`fow�jOFNCRfftANDOVER
Important tll ALTH D0 R'r
ltfl NT
forms o filling
r use 1. System Location:
only the tab key Address
to move your
� _. ...
cursor•do not /Town
use the return CI ty State Zip Code4
key, .. 2. System Owner:
Name —
L—=AK Address(If different from location)
CltylTown State Zip Code
Telephone Number
B. pumping Record
9. Date of Pumping Da 2. Quantity Pumped: - —
Gallons
3. Jype of system: ® Cesspool(s) t. Septic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
,0( 0(,:J,--
6. y tem Pumped 6y:
e
Na e Vehicle License Number
Y G k D
ompany
7. Location where contents were disposed:
w
9 ttfre of Hauler Date „
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use by�ooai Boards of Health. T60 System pumping Record must
be submit$ed to the local Board bf Meal�th or other approving authority,
n
:A. FaCiiity Information —
filling out 1 . System Location,
f
forms on Me Use, :.
only the tab key Address
to move your
rsor da
pot
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ow ode
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System Owner, Zip c
Address(If different from location) ,
,
City/Town State' p
Telephone Number
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1 Data'otPum In '
p date 2, Quantity Pumped;
Gallons
Typ®pf system Cesspool(s) ErSeptio.Tank El Tight Tank
Other(describe),
4, Effluent Tee Filter'present7...❑ Yes, o If yes, was It cleaned?
® Yes ® No
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