HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 6/9/2016 RECEIVED
_
Commonwealth Of Massachusetts y�
❑ity/I own of North Andover T N r°�F
I1O M I N ME)OVER
System Pumping Rec ord iffM..1 LlEi,ARTM 141
orm•4
DEP has provided this form far use by local Boards of Heai-h. Other forms may be used, but
information must be substantially the same as that provided here. Before using this form, chE
focal Board of Health to determine the form they use. The System Pumping Record ;rust 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. Facility infc)rmation
important:When
g p Location:
IL-n out form, 1
on the com utter,
�;o��s System
key to move your Address
use on! she tab
...
cursor-do not North Andover
use the return
key. Cray/Town — —.
State Zip Code
a
2. System Owner: ` 4
0
Name
Address(if d'r�erent from location) .... •..-...._.. .__.___..,.-.---•---..._._._.._-- -.__..._—
Stale Zip Code
Telephone Number
PUMPing Rec ord
1. Date of Pumping
Date
- 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ -ighi Tank ❑ Grea:
-
r� �
(❑ Oilier(describe): x� _---- .. .�� .___...__..:_..._..____...__._._-.--........
Q. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was ii cleaned? ❑ Yes
5. Condition of ystem:
6. Sysi m Pumped By:
Name
Ste art's Septic Service Vehicle License Number
Company _..._..... .._..._ .
7. Location where contents were disposed:
Stew "S Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Si na' le
e..of Date
Si na
eceiving Facility
Date
t5',orrn4,doc-03/06