HomeMy WebLinkAboutSeptic Pumping Slip - 2230 TURNPIKE STREET 7/7/2016 Corn
monwealth of
- - Ci Y/I—own ®i Nosh AndoVET
° . Sy-stem Pumping �
` Form 4
DBP has provided ibis form for use by loca� Boards or,iealth. Other forms may be used, r
information must be substantially the same as that provided here. Before using th1S form,
local Board of Health to determine the form they use. The System Punilping Record ;rust 1
the local Board of Health or other approvinc authority within 14 days from the purnping da`
accordance with 310 CMR 15;351.
A. Facility information
Important.When
sling out,ores 1'. Systern. Location:
on the compeer.
use only the tab
key'to move your Address l 1�1�i 1 � ❑ ___.__.. ...__.. .._..._._......... . .....---
cursor-do no',
use North Andover
the return
— —._--..._
key, sty!i oum –.._ ............. 4
• � '`ata� Zip Codt
2. System Owner: c
- Name .._.........._......... .....__..._..__.----•-w-•---.�.-----�-
I�
Cj�,yrown .__._...._......
• State._..__. ._....._--.. Zip Coda
• �
PUMPing Record Teieohone Number -.......--•�----�--•—
�.
1. Date Of Pumping D .~1_ �e, C
Date ...._.. 2. Quantity Pumped:
G2rlons
3. Type of system: ❑ Cesspool(s) ani<
p ❑ Ight Tank ❑ GrE
❑ Other(describe): ------....._
a. Effluent Tee Filter present? ❑ yes
#f yes, was it cleaned? L-] Yes �
5. Condition of System:
8. 5yst mped By:
/�C
Name
Vehicle License Number
Siewari's Se tic Service
Company `_._..... ......._ . ........ .
�. Location where contents re disposed:
Pre-treat ent P nt. 20 So, Mill Bradford, Ma 01835
Signature , aul z -~`� - _....._
Signature of Receiving Facility
t�fo-Z4.doc•03!08