HomeMy WebLinkAboutSeptic Pumping Slip - 1515 SALEM STREET 7/20/2016 _ ................
_ COmmonwemth Of Ma,sSaehuse s
- i� n Of Nosh Andover l
-SYsteM Pumping Record
LDEP has provided this form for use by local Boards or Health. Other forms may be used, but
information must be substantially-the saute as that provided here. Before using this form, chr
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.
- i
A. Facility Information
Important:'Whenj
SIFng out=oms 1. System Location:
on the computer, i
use only'he tab -
keytomoveyour Address _.. ...__........_.._._......... . .....__.__.__.�--
cursor-do not
use the return North Andover
town —
`State 3 Zip Code
2. System Owner:
S n od
Name
Address 0fd'r;erentfromlocation)--- ... .............. -- _...._._.__--_...._.._._.. ---•__----
State _._.
Zip Code
• Teieohone Number -"_._.._.,_-.,.,,,._,
�. Pumping Record
1. Date o;Pumping Date-` `-'- ....__... 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) feseptic Tank ❑ Tight Tank ❑ Grea<
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes was it clean''-d? ❑ Yes ❑ i
5. Condition f System;
6. System Pumped By:
Name
Vehicle License Dumber
Stewari's Septic Service
7• Location where contents were disposed:
Stewart's Pre-treatment Plant, 20,S0 . Mi)l Bradford, Ma 01835
1
azure of Hauser �""�----••••- ii
Dale
Signature of Receiving Facility
Hate
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