HomeMy WebLinkAboutSeptic Pumping Slip - 72 SUNSET ROCK ROAD 6/27/2016 C monwealth af Ulais�sachusetts RECEIVED
om
Ci Y[Town of North Andover
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SYStem. Dumpling Record JU
Form 4 TOWN 01Z W)
DEP has provided this form For use by local Boards of Health. Other forms may be used, but tht
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. Facifi ty Mormation
Important:When
21ing out-iorms 1. System Location:
on the computer, A
use only the tab Ak V)
key to move your Address
cursor-do not
use the return
North Andover
key, City/Town
Z wner:SYS-Lem O -state Zip Code
Name
Address(if different from location)
Gr �o.n State, '_---------
Zip Code
Pumping Record Telephone Number
1. Date of Pumping
Date 2 Y Quantity Pumped,
G Ions
3. Type Of system: ❑ Cesspool(s) al
'18eptic Tank ❑ Tight Tank ❑ Grease'
❑ Other(describe): ...... —-----
4. Effluent Tee Filter present? ❑ Yes 1-1 Yes, was it clean-ad? ❑ Yes No
5. Condition of System:
6. System.Pumped By-,
Name
Stewart's Septic Service Vehicle License Number
Company
7. Location where contents were disposed:
Ste atLs Pre-treatment?lant, 20 So, Mill Bradford, Ma 01835
iqn; ,U're, Of er
Date
I_
��gn-twe of Receiving Facil'r�y
ate
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