HomeMy WebLinkAboutSeptic Pumping Slip - 350 HOLT ROAD 7/6/2016 _ Cornmo'nwealh Of Massachusettp--CFENED
UtY/oven of North Andover
° . ..System Pumping Record t .:, ,
DEP has provided this form for use by local Boards oi ;1eak;h• Other iorrns may be useo, t
in;orrnation must be substanta[ly the same as that provided here. Before using this form,
IOCal Board of Health to determine the form they use. The System Purnping Record -must!
the local Board of Health or other approving authority within 14 days from the purnping da-
accordance with 310 CMR 15,351.
A_ Facifity Information
Important'When
fr3lingOut,fornis System Location:
on the compLjter,
use only the tab I+
key to move your Ad ress —-._._......._..._ __..-.-._.__.. ...__._
cursor-do not .
use the return North Andover
--_
key. Ctyrown ..-�_......,_. ........ _.__-------
.---.......__..._..._.. _
`Matz Zip Cod,
2. System Owner: 4
Name
lor—a-
ate Zia Code
• � Telephone Number ..."_.._.._.__.,._._.
B. PUMOng Rem®�s�
1. Date of Purnping _. :.--- _-- ...b.......
Date 2. Quantity Pumped: r
-2110
3. Type o`system: ❑ Cesspooi(s) Eg-�eotic Tank ❑ Tight Tank ❑ Grf
❑ Other(describe): - - ._._....-...,...w_..:_..._.._ - _ .._..__............_.._-..__.._ —
a. Effluent Tee Filter present? ❑ yes ❑ No If yes, was it ci'earied? ❑ Yes
3. Conditio❑f System:
�UUxx — ----
6. System PumpeA-0y:
Name !�J ----- ._--__---•.... _ _ _ _
Vehicle License Number
SieWari'S Se t1C Service License
Company
7. Location where contents were disposed:
Siewart's Pr treatrnent PI nt, 20 So, Mill Bradford, Ma 01835
Signature o`Hauler
-....._ Date'-,.�._................ ..__.._..-=.-_ --
Si na—---f—_ —_..-
9 Receivin F ��•_...__._ •,.
Date -
, OrmG.doc-03106