HomeMy WebLinkAboutSeptic Pumping Slip - 30 SHERWOOD DRIVE 6/22/2016 Commonwealth 01" Ma_�,sachusetls RECEIVED
City/I own of North Andover
— System Pumping Record (.)WNOr'I�10RI�-�F4N°,rLOVEFl
�_o 4 H� u..Ri[��i'�L�'�s7��l�ti� .
DEP has provided this form for use by local Boards of Health. Other forms may be used, buz 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 date in
accordance with 310 CMR 15,351,
A. Facifity Wormation
Important:When
Suing out forms 1. System Location:
on'he computer,
use only the tab _
key to move your Address — --_._._.._...._.,.__--••_.----
cursor-do not North Andover ,
use the re tum
key. City/Town
u -..._.,-_..,..._.,......_..
y, State Zip Code
2. System O ner:
Name
Address(if
Cityr-town __.__......_........_ ......
State Zip Code
Teleohone Number -•--._-.
B. PUMPing Record
1. Date of Pumping aa4` `..�'! 2. Quantity Pumped. -
Gallons
3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank ❑ Grease
❑ Other(describe): -----
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ Nc
5, Condition of System:
6 System Pumped B
Name -
Vehicle License Number
Stewarai s Septic Service
Company _..._...., ......._ .
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
_.. ---....__.... - ._.,. _ _._. _-
C::•e� nature o�Hsi ..-.. ..... .
Date
- ng Fil'r-•y--
Signature of Receiviac -' �'
Dzte
t5form4.doc-03/06
5vszem Pumping Record Pz,