HomeMy WebLinkAboutSeptic Pumping Slip - 145 FARNUM STREET 7/1/2016 Commonwealth OF Massachusetts RECEIVED
Nbr-LLh Andover
C -I own oi
AUG 0
-syst.em- Pumping Record
Form A
DEP has Provided this f0j'M.or use by
local Boards oiHeai"'h, Other forms may be used, I
information must be substantially the same as that provided here. Before using this form,
local 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 1a days 14COM the pumping dat
accordance with 310 CMR 15,351.
A. FacHity information
Impor-'an'tWhen
50-Ing out,or :s 1. SySttern Location:
on'the c6mpver.
use only the tab
keYto move your Address
cursor-do not
use the return North Andover
key. C-rty/-Iovvn
Zip cadF
.
2 System Owner:
dame
Address(if�dh'lerenlk from'io--( ... ....
Ut Fi wn
State Zip Code
PUMPing Record Tefe.ohone Number
1. Date of Pumping A Date 2. Quantity Pumped.
Gallons
3, Type of system:
❑ Cesspooi(s) k7l Septic Tank ❑ ight T2nk ❑ G r(
❑ Other(describe)-
4. E'll luent Tee Filter present? ❑ Yes ❑ No yes, was cleaned? ❑ Yes
5. Condition of System:
6• System Pumped B�
Stewart's Septic Service
Vehicle-T ic,—en,-s'e' Number e-r-
Company
7. Location where contents were disposed:
Stewart s Pre-treatment Plant, 20 So Mill Bradford, Ma 01835
✓Jignature o,Hauler
���Iqn ,U,e of Receiving
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