HomeMy WebLinkAboutSeptic Pumping Slip - 1267 OSGOOD STREET 6/15/2016 Commonwealth Of Massachusetts CO ;m D
9 C1' /Town Of Nbi-th Andover
Y
YStem Pumping Record ���'.,4 TOWN OF WDR7H
Form. i•i . l_1 l".i�,�D"/EW i�il,`
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 wii
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.
A. F acufaty Wormation
Important:When
21ing out forms 1. System Location:
on'the Compute
use only the t br y 1t—�" �— (!:��Id_sk.I
ke to move our Add
cursor-do not
use the return North Andover
key. City/Town
State ,1 Zip Code
2. System Owner:
nrywr
Name
Address(if different from lo(:ation)---
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping .................. 2. Quantity Pumped:Date Gallons
3. Type of system: ❑ Cesspool(s) [P/Septic Tank ❑ Tight Tank ❑ Grease T ra
❑ Other(describe):
4. Effluent Tee Filter resent?
p ❑ Yes [❑' Na IT yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By,
ADo,
Name l /
Stewart's Septic Service Vehicle License Number
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Date
Signature of Receiving Facilely
Date ......_,._ __
C,5'orm4.doc-03/06
System Pumping Record-Page