HomeMy WebLinkAboutSeptic Pumping Slip - 30 SPRING HILL ROAD 8/24/2016 Cornm' onweafth Of Massachusetts
CltYl I own of Nbr h Andover
Ystem. Pumping Record
Vc>rm 4
DEP has provided this form for use by local Boards of Health, Other forrns may be used,
information must be substantially the same as that provided here. Before Using, this loan, ,
local Board of Health to determine the form they use. The System Pumping Record rnust!
the local Board cif Health or other approving authority within 14 days from the Dumping d2'
accorda n ce with 310 CM R 15.351.
A- Facility information
impofttant•'When
'RIfins out forms 1. System. Location-
on the c6mpLr,er,
use only'he tab
key to move your Addre s
cursor-do not
use the return North Andover
key. 7ER�/-10-1 Zip Cod(
2. System Owner:
Name
Address
'ererlt�f
location)
Stale _ Zip Code
Telephone Number
Pumping Record
1 Date o-, Pumping 2. Quantity c r:IV ED, Vl-� Ga-I—Jons
4, 3. Type of system: ❑ CeSSP001(s) 0"'Septic Tank ❑ Tight-fan; Gr(
Other(describe):
L
4. Effiluent Tee Fifter present? ❑ Yes 2--No If Yes, was it cit-aned? F] Yes
5. Condition of System:
6, Sy 'AemurnpeO_B�-,,
L Name _
S.-tewarL's Septic Service Vehicle License Number
Company
7. Location where contents were disposed:
Stewar�t's " Plant, 2 So, Mill_Bradford, Ma 01835
igna ure 01 Hauler
'Signature of
Receiving y ... .........
Date
15f0--M,4.doc-03106