HomeMy WebLinkAboutSeptic Pumping Slip - 1635 OSGOOD STREET 6/16/2016 Commonwealth of Ma,,�sachusetts RECEIVED
F North Andover
City/ I own of
Ystem Pumping Record TOWN�T @�`I3 TH l❑❑ER
�_
' x o 4 V U i..
DEP has provided this form for use by local Boards of Health, Other forms may be used, but
information must be substantially the same as that provided here. Before using this form, chi
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
Important:When
511ing out form.s 1. System Location:
on the computer, d
use only the tab (1:4P key to move your Address --
..__..__._...------,__.., __..._..._.,._.---
cursor-do not
use the re'um North Andover
key. City/i own --- .- _
Mate Zip Code
2. System Owner:
AD °,
Name -_._.—.._., .._......_
Address(if different from iocation) — .
C4/Toown --- ._. .._........- .
State - _._.—.-
Zip Code
Telephone Number
�. Pumping record
1. Date of Pumping -. _.� �...` .,. ._..
Date 2. Quantity Pumped:
Gallons
3, Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grea,
❑ Other(describe): —.------........_,_......__..:_.,,_,.�.____..__._.._..__...... .
a. Effluent Tee Filter present? ❑ Yes ❑ No if yes, was ii cleaned? ❑ Yes ❑I i
5. Condition of„System.
6. System Pumped By:
N-=
ame
---- __-- --......
.
S Vehicle License Number
tewart's Septic Service
Company —
7. Location where contents were disposed:
Ste art's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of
w_ _...._.__—
Date _,____
Sign aturepew,
--__.-_
Facili
z5fo~n4,doc-03/06