HomeMy WebLinkAboutSeptic Pumping Slip - 457 BOSTON STREET 8/11/2016 Commonwealth OB Massachusetts
Y - City/ n of Nbrt-h Andover
Ys�e Pumping Record
- Ir=on 4
DEP has provided this form for use by local Boards of Health, Other forms may be uses
information must be substantially the same as that provided here. Before using this your
loco! Board of Health to determine the form;.hey use. The System Pumping Record mu;
the local Board of Health or other approving authority within 14 days from. the bumping e
accordance with 310 CMR 15.351.
A- Facifity Jnformat�on
tmPo,.tant;'When .
sung ou";or,,s 1. System location:
on the computer, r �
use only the t `�"t ab S
key to move your Address
cursor-do not Nor%h Andover
use the return
key. C`t�yrawn .._ _..._..... . ......... ....
aze > Zip C
2. System Owner:
O
Name ------ — -
Address(if dMerent from loc2tion) "— . ..
• Cityrawn ._--.__... .._.......... ...
State Z P Cc
Telephone Number__...._._.._.._.__.__._
. PUi Ong Record
1. Dote of Pumping _ � �
g Gate 2. Quantity Pumped:
RECEIVED Gallon:
3. Type of system: ❑ Cesspool($) e tIC rank :t ht Tank C.
14 2,016 i' N OF NOR' %k AP`Jl ) frB'' ❑ Other(describe): =-
V§EPkk.al Y DlwfaARTM16`eP't° '
4. Effluent Tee Ritter present? 'yes a
(f yes, was it Cleaned? I ( deg
5• Condition of SySiern;
`f
5. system Pumped By;
Name
f° `Vehicle License Number-
Stewar1's Septic Service
Company ------ _..._— ...... .
7. location where contents were disposed:
S e arc's., ?re
-treatment Plana' 2,0-oo Mild Bradford, Ma 01835
signature apt r „ - __' �. ......
Date •.__°_,..._.__.�.
Signature o,Receiving Faailr y _.,
Date ......_.._-
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