HomeMy WebLinkAboutSeptic Pumping Slip - 234 BRADFORD STREET 8/17/2016 Commonwealth Of Massachusetts
City/ I own of Nbrth Andover
t Sys�em_ Dumpling Record
Form 4
DEP has provided this form for use by locaE Boards of Health. Other 1OFMS May be usec
information must be substantially the same as-Lha-( provided here. Before using Till's fore
local Board of Health to determine the fOFM they use. The System Pumping Record mu:
the local Board of Health or other approving au-Lhojity within 14 days from the Pumping
accordance with 310CMR 15.351.
k FacHity Informa-bon
ImPOiTtantc When .
filling out fom"S 1. System Location:
on the computer.
use only the tab
key to move your Address
cursor-do not
use the return North Andover
key. City/ ......
65r ' aze 2fp� '
2. System Owner:
Name
Address(if difffierent from location}
State Z;0 Cc
B. Pumping Record telephone i umber
Rki"CEIVED I. Date OF Pumping � r
, Qua o
Date Quantity y Pumped
kb J 4 2 M t 3. Type of system:
J Cesspool(s) DSeptic Tank L
D T ight Tank ❑ C,
I'MN 0 N(DR M`H ANDOVER
I iEALJI I DE ❑ Other(describe): ......
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? Yes
5. Condition of System: ')
C) ry
...........
6. System Pu. ed By:
-----------
Name
Szew�a�r�sSe�tic-Ser�vice Vehicle License Number-
Company
7. Location where contents were disposed:
zlvw��alr�-�'�\,'Dlre-t'L,re�e'Lmen't Plant 20'S'0--IV
NI Bradford, Ma 01835
Signature-ei Hauler
�iqnture�ofR��em�g��ccjj�� - Date
5�o
' -_-__,14-d0c-03/06' '