HomeMy WebLinkAboutSeptic Pumping Slip - 179 HAY MEADOW ROAD 8/15/2016 Commonwealth Of Ma•ssachusetts
y '
own o h Andover
Cit /I— -Z
Nor'L o
i
-,SYStem PuMPNng Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be usec
information must be substantially the same as that provided here. Before using this farn
local 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 pumping
accordance with 310 CMR 15.351.
A- Facility lnformat:()n
impo,'Larl't When
1911ing Out for.ns 1. Systern Location:
On the computer,
use only the tab
key'to move your VU
cursor-do not Address
use the return North Andover
key. 7E'r' /T-"_
2. System Owner:
N., aJaL ------
Address Ci��dil,,'erent�fromi_o_�tjon) ...........
Zk/Town .........
State Zip Cc
i efeOhone Number
B. Pump'3ng Record
1. Date 07 Pumping 0
2. Quantity Pumped:
pate Quantity
Gaflon4
3. Type of system. ❑ Cesspool(s) [4'1Septic Tank ❑ Tight"Fank ❑ C.
❑ Other(describe):
RECEIVED
4. Effluent Tee Filter present? El yes ❑ No
j yes, was itclean�ed? ❑ Yes
016 5. Condition Of ystern:
fl
6, System Pumped By:
ON]
Name ........
Stewa_��_-s�,Setic e Vehicle License Nurnber
Company
7. Location where contents were disposed:.
tew ZLs Pre-treat
ment Plant, 20 So, mill Bradford, Ma 01836
S ig w tu
f It!ler
Date
Signature of
P
cii�
eceiving achy pate
54o m4.doc 03106