HomeMy WebLinkAboutSeptic Pumping Slip - 10 STONECLEAVE ROAD 7/8/2016 VJ
Commonwealth ®s Massachuse""'
fts
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Ity/I—own of Nbr'Lh Andover
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SYstew- Pumping Record
orm 4
DEP has Provided this form for use by local Boards of Health, 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 1
the [ocaj Board of Health Or other approving authority within 14 days from the pumping da'!
accordance with 310 CM R 15.351.
A. Facffi� Inforrnation
Important'When
'IlIkIs out forms Systern Location:
on the computer.
use only the tab
key�O move Your C-b
c ,-
cursor-do no'Z Address
use the return North Andover
key. Qlfty/T own
Zip C06
4-2!:�A 2. System Owner:
Address(if dr,eren,,from
Code
Tefepho41e Number
B. PurnOng Record
1. Date of pumping
2. Quantity Pumped:
ate
D6L Galion
3- Type of system: ❑ CessPOOI(S) �,Septi, T,,k El '�T
ight Tank ❑ Gr(
❑ Other(describe):
4. Effliuent Tee Filter Present? ❑ Yes R--N-�o— If yes. was'it'Cleaned? ❑ Yes
5. Condition OfSystern-
6. 'SysTerolumped8
u
W7�u
Name
t wa,_.s Vehicle License Number
I tic Service
ew'@IE's eptficc��,,j.
!11�SSe �-, Sew�,
Company
7. Location where contents were disposed;
Stewart's Pre-treay'nent Plant, 20 So Mick
Signature—of Receiving
'&"orM4.doC-03/06