HomeMy WebLinkAboutSeptic Pumping Slip - 350 SHARPNERS POND ROAD 6/24/2016 Commonwealth Of Ma,,�sachusetts RECEIVED
Andover
System Pumping Record
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1,EAJI-i DEF,ARTME 1
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 wi
local Board of Health to determine the form they use. The System Pumping Record must be submi
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
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Important:When
filling outforms 1. System Locab n:
on the computer, �a
use only the tab ... %
key to move your Address — -- –( eY
cursor-do not
use the return North Andover
key, t, w/Tn — —--- _
State Zip Code
2. System Owner.
' Name _.....__ .._..... .. ......__._.... - -�..- -- --- —
—
Address(if different from location)
CityTown _ -........ ..
State ---'—
Zip Code
Telephone Number
PUM ling Record
1. Date of Pumping pate f � _
-.__�` L.._.l._ ........ 2. Quantity Pumped:
`1 Gallons —
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tank Ti ht
9 ❑ Grease Tra
❑ Other(describe): _ _._....__.-- ---
4. Effluent Tee Filter present? ❑ Yes r No
/[ _ If yes, was it cleaned? ❑ Yes % No
5. Condition of System:
5. Syste Pu ed
;. /l/:3
Saewarts -- --- - __..—._..__._....-----
?/ Vehicle License Number —
' Septic Service
Company _-._..... ..,..._ .
7. Location where cone nts were p sed
Stewart'" P ea' e t P i, 20 0, ill Bradford, Ma 01835
Signature of uler -"'- ° ---
Date _.._.-.._. _-----
Signature of Receiving Facilrty
Date —
t5forM4.doc-03106
System Pumping Record-Page