HomeMy WebLinkAboutSeptic Pumping Slip - 54 LONG PASTURE ROAD 6/3/2016 Commonwealth of Massachusetts RECEIVED
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City/I awn of Nbr-th Andover 'AA, .e
�. Ystem Pumping Record TOWN OF NORIHAK)O R
-r Y
Form iGF V i1wV lDi"�4)AR�1Ww�(vJ
DEP has provided this form for use by local Boards of Heaiih, Other forms may be used, bui
information must be substantially the same as that provided here. Before using this form, chc
local Board of Health to determine the form they use. The System Pumping Record must be
the local Board of Health or other approving authority within 14 days from the pumping date i
accordance with 310 CMR 15,351.
A- FacHity Wormat11on
Important:When
suing outfoms 1. System Location:
on the computer, lz)
use only the tab ) I
key to move your Address — - ---. ..-__.__-_. .._._._..
cursor-do not
use the retum North Andover
key. City/ own
State Zip Code
2, System Owner:
Name — .. .._.....__
mu;r
Address(if dffferent from location) — _ . .
C'tyrown
state Z ip code
Telephone Number
Pumping Rec ord
1. Date of Pumping Date ___.. , C
2. Quantity Dumped:
Gallons
3. Type of system;
CeSSP001(s) Se `uc Tauk ❑ ightTank ❑ Grea.
❑ Other(describe): _ - ....._,_.-....__.. _._..
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was ii cleaned? ❑ Yes ❑ i
5. Condition of System:
6. System� Pumped By:
Name
Vehicle License Number
_Stewari's Septic Service
Company _..... ......._ .
7. Location where contents were disposed:
Ste ar's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Sig ah ure # - __..... --_
Date
t. Date
Signature ceiving Fact ity- 3
.5t0-74.doc-03/06