HomeMy WebLinkAboutSeptic Pumping Slip - 547 SALEM STREET 7/12/2016 COM 1[11V'CEM; D
Monwealth Of lfts�sachusetts'
ityll own Of Nbr-th Andover AU Rj C., 0 ,8 U
m. Pumping Record
DEP has provided this form for use by local Boards of Heal',,h. Other forms may be used, t
iDfOrmatlOn must be substantially the same as-that provided here. Before using thli$7'01-M, I
local Board of Health to determine the form they use. The System Pumping Record must!
the local Board of Health or other approving authority within, 14 days 11-0-M the pumping da-
accordance with 310 CMR 15.351.
A- Facility Information
Impoi—tant•When
sil U n 9 o ut,-;o r,D s 1 System Location:
on'the c6mperer.
use onfy'the tab
key'to move your
cursor-do nolk
use the returin North Andover
`S?ate Zip Coda
key. Citty/—i own
2• System Owner-
Address(if di,".erenk from-To-c�ifo—r),—,
Stale Zip Code
Pumping Record
1. Date of pumping "'- ............
Date 2 Quantity Pumped: Gallons
3. Type of system: ❑ Cesspoof(s) 9-<eptic Tank ❑ Tight Tank ❑ GTE
❑ Other(describe):
4. Effluent Tee Filter Present? ❑ Yes ❑ No l-"yes, was it cleaned? ❑ Yes
5. Condi'tio n f System:
rn
6, Syste Pumped By:
Dame -V-e,-,h—icleli'c—en- sle--NumberStewart's Se tic Service
Company
7. Location where contents were disposed:
Pre-treatment Plant, 20 So. Mill Bradford Ma 01835
Signatu auier
Date
Date