HomeMy WebLinkAboutSeptic Pumping Slip - 230 LACY STREET 7/7/2016 Commonwealth Of Ma,-§sachusetts
Nbrith Andover City/ I own ol AUG J
-System. Pumping Record
Foe 4
DEP has provided this form for use by local Boards of Heai",-h. Other forms may be used, t
information Must be substantially the same as that provided here. Before using this-,'oj-n, (
local Board of Health to deter-mine the form they use. The System Pumping Record ;must 1
the local Board Of Health or other approving authority within 14 days from the Pumping dal
accordance with �10 CM R +5.351.
t th Iro
A. Facility information
IMPortant:•When
Ming out 4mr'ns 1'. SYStern Location:
on the computer.
use only the tab
key to move your
cursor-do no Address
use the retw n North Andover
key. CirtWown
Zip Cod(
2. System Owner-
_Name
Address(if d'rerent from location)
' '�f_zo-rl .........
State Zip Code
EI_ Pun0in__Re_c_or________----
1. Date Of Pumping
Date Quantity Pumped:
3. Type af system: ❑ Cesspool(s) Septic Tank ❑ T ight Tank ❑ Grt
❑ Other(describe):
4, Effluent Tee Filter present? C] Yes If Yes, ..was.iticiean'ed? ❑ Yes
5, Condition of System:
Pumped By
Name-ame
Stewart's 5e tic Service Vehicle License number
Company
7. Location where Contents were disposed:
S- P re-tre atment Plant, o So Bradford,
Sig"t,11 of Haute
Date
Signature of Receiving_F=a.,i'r(y_
*for'-.14.doc-03106