HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 6/29/2016 Commonwealth of Massachusetts RECEIVED
❑itY/own of Nbrith Andover
..Sy
tem- P JL4
SY ump�ng Record
Form 4 J'OWN F NOR I'H!;
DEP has provided this lomn for use by local Boards of Heai;h, Other forms may be used, t
inform, ation must be substantially the same as That provided here. Before using li'll'S T-OTM,
10caf Board of Health to determine the form they use. The System Pumping Record must i
the local Board of Health or other approving authority within 14 days from the pumping dal
accordance with 310 CMR 15.351,
A. Facifity Wormation
IMPOI Lent:When
'511ing Out forms I- System Location;
on the c6mpu,,er' )',A
use only the tab k
key to move your Address ------
cursor-do not
use the return North Andover
key, city/'—]own ---
2. System Owner:
I\j
Name ------
Address(if di�lerent for location)
/T�o-n
State Zip Code
Telephone Number
1. Pura
Date Of Pumping
Oath Quantify'te L Ly Pumped. Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank T igh�(Tanlk GrE
D`/Other(describe): 7-
4. Effluent Tee Filter present? ❑ Yes ❑ No If es, was ii yes
5. Condition of SVstem:
6
6. Sys-Lem Pumped By:
Name
Stewart's Se tic Service Vehicle License Number
7. LocaLi
on where contents were disposed:
St a re-treatment Plant, 20 So. Mill Bradford, Ma 01835
Sig of Ha
Date
Chat c
'Y
Date
'5for_'114.00c-03/06