HomeMy WebLinkAboutSeptic Pumping Slip - 107 GRANVILLE LANE 7/1/2016 k
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Commonwealth of Massachusetts ALIG1, 01,M16"",
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C ty/T
own of Noy th Andover
ri
.System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check wi-',
local Board of Health to determine the form they use. The System Pumping Record must be submi
the local Board of Health or other approving authority within 14 days fro,n the pumping date in
accordance with 310 CMR 15.351.
A. Facility Informati®n
Impor'Lant:When
51iing out'jorms 1. System Location:
on the computer,
use onfYthet tab
key to move your Address
cursor-do not
use the return North Andover
key, City/Town
Zip Code
2. System Owner:
Name
Td—dress(if—different from location)
State Zip Code
Telephone Number
B. PUM
1. Date of Pumping -6�a§te 5� 2. Quantity Pumped: ) Con
Gallons
3, Type of system: ❑ Cesspool(s) Septic Tank ight Tank ❑ Grease Tra
❑ Other(describe):
-----------
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was'i('c('ean-ad? EJ Yes
❑ No
5. Condition of System:
6. -Y-stem Pumped Bv,.""%
01
Name
Stewart's Septic Service Vehicle License Number
Company
7- Location where contents were disposed:
St
(eW2FF"R Pr,--trszm'mp-+ Plant, 20 So. Mij€_Bradf.o,rd,Ma 01835
1�5e of Hauler Date
Signature�cf Receiving Iy ............
Date taforr-.14.doc•03106
System Pumping Re=d-Page 1