Loading...
HomeMy WebLinkAboutSeptic Pumping Slip - 122 OLYMPIC LANE 8/10/2016 Commonwealth 0f Massadhusetts City/I own eF Nbr-th Andover -. , . . Yst m- Pumping Record `T o Form 4 LDEP has provided this form for use by local'Boards of Heal;h. Other forms may be usec information must be substantially the same as that provided here. Before using this for focal Board of Health to determine the form they use. The System Pumping Record mu: the local Board of Health or other approving authority within: 14 days from?the pumiping c accordance with 310 CMR 15,351. A- Facility Info>r atop rmpo,ant_when . Iiliing out fours 1. System, Location: on the computer, use only'he tab ^^ f key to move your Address I cursor-do not use the return North Andover !fay. C'tcy/T own ....... . ...............:.. .. .__.._..._.. _ - tat� dip C, w 4 cr 2, System Owner: -------- Name Address(if diuerent from location) — ._.. 'Ed y>i own ._,-•_- .............. . State 2iP Cc ' Pu p'ing Record' i arephone i�Jumoer �. 1. Date of Date Pumping -..._._._.__..._�� .............. 2 Quantity Pumped: i 3. Type of system: ❑ s Cess ool p ( ) Septic Tank ❑ Tight Tank C EJ ©th � C �� h�� � er describe): — _ .._.._. _ .,._.._..........,._ 4. Effluent Tee Filter present? ❑ Yes [:�' if yes, was i t clean:-d? 17 Yes TOWN(,)F NOF'MI PNjOVER 5. Condition of System: 4°i X44 I I I Dtl.PAR WM wok 6 ct 1/ 6. System=-Pump d By: Name Vehicle License\umber Stewari's Septic Service Company _..._., I Location where contents were disposed: Siwar's..,°re-treatment Pla 20 So. Mill Bradford, Ma Si natur il 9 aofhraer�r —.____....__..... - _.,.... Daze - .. . ... ..__._.._-._- Si nature of _ g Receiving Facirr�,y . ._ ..._.._.. _...._. t5;orm4.doc-o3/0