HomeMy WebLinkAboutSeptic Pumping Slip - 336 BOSTON STREET 8/8/2016 Commonwealth of Ma,'�sachus
Nosh Andover
CitY/I own ®z
System PumPing Record
-ore 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, t
informadon must be substantially the same as that provided here. Bejore using this form, ;
iOcaf Board of Health to determine the form They use. The System Pumping Record must j
the local Board of Health or other approving authority within 14 days from the pumping da:
accordance with 310 CMR 15.351.
& Facility information
Important Wien
11fing oTkfor'ns 1. System Location:
on the c6mpLj'er.
use only the tab
keyto move your Tddress
cursor-do not
use'the return North Andover
key, Z'r' ]Tov- Zip C06
2. System Owner:
S Name ---------
'ilp
state
•B. PumOng Record Telephone Number
7. Date of Pumping
Date uantity Pumped:
3, Type of system: ❑ Cesspooi(s) Seotic
eptc Tank ight Tank ❑ Cr(
❑ Other(describe)-
4. E'll luent Tee Filter present? ❑ Yes If yes, was ii cleaned? ❑ Yes
5. Condition of System:
6. System Pumped By,-
Stewarts Seetic Service Vehicle icense Number
Company
7. Location where contents wer - used;
k' Pre-ireatrneni nt, 20 So. Mill Bradford, Ma 01835
19 ture of er
- --
Signature of Receiving ,y -Date—
t6'0--r-14.0oc-03106