HomeMy WebLinkAboutSeptic Pumping Slip - 1112 TURNPIKE STREET 6/26/2016 Commonwealth Oil: Ma,�-,sachusetts IRECEIVED
City/Town Of North Andover
.system Pumping Record JN i �� U1
8jEA Tl1f E'f1 RTiVH"Ni
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
!ocal 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 CM 15.351-
A. Facafity Wormation
Important:When
suing out forms 1. System Location:
an the computer, �' )
use only'he tab
key to move your A dress
cursor- not North Andover .
use the return
key. C'rtyfTown _ __--_..._.._........ .
Stat2 Zip Code
4 ,
2. System Owner:
PV
Name � . 1 )0
-.._,......_................_ ..-. .........
Address(ifd'fferen2from loc2tion) ___.- .--------. _�-------_.---
City/Town
State , .-
zip Code
Telephone Number
. Pumping Record
1. Date of Pumping
pat 2. Quantity Pumped;
_allons
3, Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease
❑ Other(describe): /No 4. Ef fluent Tee Filter present? [7 Yes If yes, was it cleaned? ❑ Yes ❑ Nc
5. Condition of System: (�
c
6. System Pumped By:
..- /y
Name
vehic L ic—en se Numbe r
_Stewari's Septic Service le
Company
7. Location where contents were disposed:
-. ewarf's,-Pre-trea�me, f 'Iant,`20 So. Mill Bradford Ma 01835
{
t
S 19 n; �5 e _.___.-
Date _ — _--
Signature of Receiving Facilrky
Date
t5fom4.doc-03/06
Svstem Pumping Record-Pa