HomeMy WebLinkAboutSeptic Pumping Slip - 107 ROCKY BROOK ROAD 8/4/2016 C orn monwea'lth of Massachusetts
th And over
C Y/Town of Nbrt
SYstem Pumping Record
orm 4
DEP has Provided this form for use by local Boards of Health. Other forms may be used, but th(
information must be substantially the same as that provided here. Before using this form, check
local Board of Health to determine the form they use. The Sys-L em Pumping Record must be su
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 C M R 15.351.
A- Facility Wormation
Important'When
•5111ng outforms I. System Location:
on the camper. r , '. *o(, �
*O' V' I
use only'the'tab &ss" ...........
key to move your AdgresO-
cursor-do not
use'the retum North Andover
key. CitylTown
—..._..__......? ........__., p,-C*-o-d—e
2. SySLeim Owner:.
WQ
Name
Address Cif 7different deferent from
C itty/T own
State Zip Code
Tele.ohone Number
RECEIVED B. Pumping Re6ord
1. Date of Pumping
Date 2. Quantity Purnped:
"[4-1 14
-U I b 3. Type of system: ❑ Cesspool(s) Gallons
"10WN,0r` MM(WER Septic Tank ❑ Tight Tank ❑ Grease'
iEX,"-j'H DEJ`A[(TMS1 F
❑ Other(describe):
4. Eff luent Tee Filter present? ❑ Yes [] No If yes, was'it'cleaned? ❑ Yes ❑ No
5. Condition of& tern:y
1Q11
6. System Pumped By:
Vehicle License Number S t e wart's Septic Service
Company
7. Location where contents were disposed:
Pr -try Mill Bradford, Ma 01$35
Sig :P'r I e
re 79uler
Date
Signature of Receiving Faailry
Date ........
k5'-Orrn4.doc•03/o6
System Purnoino Recor(i-ppr