HomeMy WebLinkAboutSeptic Pumping Slip - 58 PADDOCK LANE 8/19/2016 CoMmonwealth 01c Massachusetts
Nbh Andover
City/I own of rt
M
ystem Pumping Record
Form'4
DEP has provided this i0rM for use by local Boards of Health. Other forms may -be usec
inform. a-don must be substantially the same as-that provided here. Before using this four
local Board of Health to determine the form they use. The System Pumping Record mu;
the local Board of Health or other approving author within 14 days from the Dumping
accordance with 310 CMR 15,351.
A- Facility Information
lmpo-'Lai-it When
511ing Out Torms 1. System L 11-0
On the computer,
use only the tab
key to move your Address -----
- ......
cursor-do not
use the return North Andover
key. Z-t /�T-
ate .Zip.0
2. System Owner-
Z, /T own -State-----
Zip Cc
ielePhone Number
PUMPing Rec'ord
I I
Date of Pumping 2, Quantity Pumped:
RECEIVED DeLe 4Y CL
Gallons
3. Type of system: Cesspool(s)
v
i / e pt i c T a n k
fight Tank C.
Other(describe):TOWN OF Norzi,�q/tij�lD(,)VER ❑
HEAL H D[_['AR1!1v1,'_-A�rr
Effluent Tee Filter present? ❑ Yes ❑ NC If Yes, was ii cleaned? ❑ Yes
5. Condition of system:
6. <',Rtem Pvmped By:
Name
Stewart's Septic Service Vehicle License Numt�er
Company
71 L 1.
where contents were disposed:
Stewart' Pre-treatment Plant 20 So. M,l,[_B?8dford" Ma ,01835
ig ature O'H uier
Dat te
Signature o.Receiving achky
date
2s a-n4.aoc 03106