HomeMy WebLinkAboutSeptic Pumping Slip - 200 HAY MEADOW ROAD 7/27/2016 Commonwealth of Massachusetts"""!!!
C Yl I own of Nbrth Andover A"6
Ystem Pumping Record
nor 4
DEP has provided this form for use by local Boards ol -ieal'h. Other forms may be used, but
information must be substantially the same as that provided here. Before using this form, ch'E
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. FadlitY InfOrMation
Important'When
1911ing out ours 1. System Location:
on the computer'
use only the tab
key to move your Ad-d ness
cursor-do not
use the return
Andover
key. C'sV-jown
2. System O\Jnef:
Address(if diriffiBrent from location)'__
ZFIy/_i�Own _ --------
PuMp'ing Record
I. Date of Pumping 2, Quantity Pumped: SJ
Gallons
3. Type of system: ❑ Cesspool(s) is Tank
❑ Tight Tank ❑ Greas
❑ Other(describe): ------
4. Effiuent Tee Filter present? ❑ Yes � o if yes, was it clearied? ❑ Yes El
5. Condition of System:
--------------------------------
6. ,-ys,, urnp y:
t
Nam
m
AStewarVs eptic ,Service. Vehicle License Number
Company
7, Location where contents were disposed:
Stewa K Pr tment Plant, 20 So-. Mill Bradford, Ma 01835
Signature ofHauler
.-_--....__.....----••-.._
71—
Signature Tof Receiving_ji��r
Date te .......
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