HomeMy WebLinkAboutSeptic Pumping Slip - 415 BOXFORD STREET 6/17/2016 Commonwealth Of Massachusetts RECE,11,1VED
City/Town Of forth Andover
System PumOng Record
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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 wi'
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 15351.
A. Faci ity Wo rmation
Important:When
51ling out forms 1. System Location
an the computer, ' `. >
use only the tab
key to move your
the not
-return North Andover
use the return
key. City/Town
State Zip Code
2. System Owner: >1
r
Name • .
Address(if different from location) — "
City/T own --- ._...._......... ..
State Zip Code
Telephone Number
B. Pum ing Record
1. Date of Pumping -Date 2. Quantity Pumped:
Gallons
--
3. Type of system: ❑ Cesspool(s)
Septic Tank
�s p` ❑ Tight Tank ❑ Grease T ra
❑ Other(describe):
4. Effluent Tee Filter present? ,Yes )No If yes, was it cleaned? ) Yes ❑ No
5. Condition of System:
s
% -------- ..
6. System urns d,.B.,.._
y
am ,' r -- � r
N
e _ �.. _ _ ..,... ....
Vehicle License Number -
Stewart's Septic Service
Company _.__._.. .. .._..._ . ...._...
7. Location wh r tents w re di s used;
Stewartt's P g lant, ''So. Mill Bradford, Ma 01835
Signature of H ler - ... .
Date
Si nature of Receiving Fac -
dais --
tSfom4.doc-03106
System Pumping Record-Pape i