HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 6/18/2016 S-'\ Commonwealth Of MaSsachuseils
= ❑ yf T own ow Nbr h Andover RECEIVED
° .system Pumping Record
nor 4
y ii )d Nr�I)� I'_V'w�
DEP has provided This ,orm tar use b local Boards ol H r Torms may be used, bui
information must be substantially the same as that provided here. Before using this form, chE
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. Facifity Wormation
lmpor`anf:When
fi1Hng out-To ms 1. System Location:
on'he corn crier,
use only''the y o '3'Address �
key to move our , =—�-4" _...._..___..-.---.__. ...__._
_._....._.._._.. .
cursor-d0 not
use the return North Andover
key.
Slate Zip Code
2. System Owner: '
Name
I�
Address(if dFflerent from location)
Ctyrown --•--._...._.
State _._.—._
Zio Code
Telephone Number
B. Pumping Record
I. Date of Pumping ------
2. Quantity Pumped, Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ ;fight Tank IGre2:
❑ Other(describe): .._....._...:_..._..
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑
Yes Fi 5. Condition System:
- ...
6. System Pumped Pumped By:
/ 4
Name
Vehicle License Number
Stewart's Septic Service
Company �..._....
7. Location where contents were disposed:
Steward's prUreatmen`, + nL"; 0 So. Mill Bradrord, Ma 01835 -
,T
w�-
Signatu ler - .. ..... -
Date
Si natu -
eiving Facility
Date ...._.._
,5 0, 14.doc-0,3/06
Commonwealth Of Massachusetts RECEIVED
❑RYT-1 own Of Nbrth Andover
P� cord
d orm 4 TOWN OF NOR T. l Al it f(')v/FR
K LIH DEFAR�MErgT
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
local Board of Health to determine the form they use. The System Pumping Record must be su
the local Board of Health or other approving authority within 14 days from the pumping dale in
accordance with 310 CMR 15,351.
A. Facifity Wormabon
Important:When
5lling out forms 1, System Location:
on the computer, e !I t
key I use only' tab Add ress move your U/
..----._...._...._...
cursor-do not North Andover
use the return
key, City/Town _.._......... . ......... .........
".State Zip Code
2. System Owner:
• Name _..... .. ......__.....------_...--•---
Address(if different
Citty/T own
State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping - - -
Date e ......._._ 2 p
. Quantit y Pumped. Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tat*p` ❑ Tight T any ,ease-
❑ 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
Stewari's Septic Service Vehicle License Number
Company —
T Location where contents were disposed:
Stewart's Pre-t tment Plant, 20 So. Mill Bradford, Ma 01835
Signat f.Giaule
- Da'pe j
Si ria re of Rece
g � g Facility ._ .. .. ... ......
Date
t5`0m4.doc-03/06
Svstem Pumoino Record-P.r