HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 7/29/2016 Commonweal
th O' Massachusetts
C
Ity/ I own ®f Nbrith Andover A U G' (j 8
. t i
M
-SYstem- Pumping Record -7.0
-OrM 4
DEPI J F',1,1
DEP has provided this form for use by local Boards of Heai",-h, Other;owns maybe
used, k
information must be substantially the same as that provided here. Before using this fora,,
local Board of Health to determine the form they use. The System Purnping Record must j
the local Board of Health or other approving authority within 14 days from the Dumping da,
accordance with 310 CMR 15.351,
A. Facility fir ormation
Impo;'cant When
filfing out forans 1, System Location:
on the computer.
use only'thet tab
key to move your Address
cursor-do not
use the re"Mm NNosh An*Andover
'
key. CKY/T own .......
2. SYSIzern Owner:
e6Yf
Name
Address
C't I own
state Zip Code
Telephone Number
PUMPing Record
1. Date of Pumping
Date 2. Quantity Pumped. C
Gallons
3. Type of system: EJ Cesspool(s) ❑ Septic Tank ❑ Tight Tank R"'&-E
❑ Other(describe):
7-
4. Effluent Tee Filter present? ❑ Yes ❑ No if Yes, was it clewed? ❑ Yes E
5. Condition o System:
6• System Pumped By.-
Stewarvs Vehicle License Number
Company
7• Location where contents were disposed:
StewafTs Pre-` ,
iment Plant, 20 So, Mitl Bradford,
_Ma.0183.5
,q,,w,e c,,Hauer
Date
iqnkure Toi Receiving--Fia7
ty
Date.-I
15"0--71-4-dOc-03106
Commonwealth ®s
C_ I
--h Andover _R
RYI I own af NbrL
S e
Yst m- Pumping Record
Form A.
DEP has provided this jorm Or use by local Boards of i eal h. Other forms may be used, t
information must be substantially the same as that provided here. Before using this form ,
local Board of Health to determine the form they use. The System Pumping Record must!
the local Board of Health or other approving au-L,1_1o$-ity within 14 days frorn -Lhepurnping da•
accordance with 310 CMR If 5.351.
A- Facility information
lmpoi When
filling Our,forn,S 1. System, Location:
on the c6mpmer•
use only the tab
key to move your Address
cursor-do not
use'the return No;<h Andover
key. C•Ly/Town
Zip codE
2. System Owner:
Name
Ad�dress
OfdH`lerentfronTio�t*n_)___-
C*k own
State Zip Code
Purn0ing Rec'ord'
I. Date(a, Pumping ate 2. Quantit Y Pumped:
G2 ons
3. Type of system. ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank L-1 GrE
❑ Other(describe):
4. Efiiuent Tee Filter present? ❑ Yes If Yes, was it cleaned? f-] Yes
5• Condition of System:
6• 5ystern Pumped By-
StewaL�_�s�Se tic�Servir�_e Vehicle License Number
Company
7, Location where contents were disposed:
Stew r�"sere-treatment ent Plant, 20 So, Mill Bradford, Ma 01835
Signature
Signature of
commonwealth Of Massachuse#�,µ
City/ I—own of Nbrth Andover
= :system- Pumping Record
DEP has provided this form for use by local Boards of Health. Other forms may be used, k
inforrnation must be substantially the same as that provided here. Be;ore using this form, ,
local Board of Health to determine the form they use. The System Pumping Record ,:lust i
the local Board of Health or other approving authority within 14 days from the pumping da•
accordance with 310 CMR 15.351.
A- Facility Information
lmpor,ant'when
19114`ngou,;oms 1. Systerrl Location;
on the compttb I I
use only thet an
key to move your Address
cursor-do not Nq�h Andover
use the return
key. City/T own --.....-. .
Zip 0001
2. System Owner. ; P
-_ � N -.___— v
Name _...-----•----
slate Zip Code
• "telephone:`lumber -.._...-.._.._.__.—
B. Pump ng Rec®r E
1. Date o;Pumping -.-(_��!_ _ ._.....__. .... ��
Gate 2• QuBntlty Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank + Grf
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No !;yes, was it cleaned? ❑ Yes �
5. Condition of System;
5. System Pumped By:
Vehicle License Number
Szewal�'s Septic Service
Company __ ...
7. Location where contents were disposed:
rt's Pre-treatment Plant, 20 So. Mill Bradfgrd, Ma 01835
Signai