HomeMy WebLinkAboutSeptic Pumping Slip - 115 SPRING HILL ROAD 8/24/2016 Commonwealth Of lassachusetts
C ity/T own o"I' Nbi I
th Andover
Est st m- Pumpng Record
Fon-n 4
DEP has provided this form for use by local Boards of Health, Other forms may be usec
infor, ation must be substantially the same as Thai here. Before using this fors:
local Board of, Health to determine the form they use. The System Pumping Record mu:
the local Board of Health or other approving authorii-ty within 14 days from the pumping
accordance with 310 CMR 15.351.
A- Facility Information
Impo,'Lant:When
1911"ns'out`orris 1. System Location:
or?the romper.use Only the tab
key to move your
cursor-do not North
use the retum -Andove r
key, Utyf-lown
Zip G
2. System Owner:
Name ...... -------
Address(if di.",erenl from-location) -------
Z, /�Tov,n ......
State ZP Cc
RECEIVIED B. PurnP' ng Record r ele.ohone Number
Date OF Pumping
�y Purnped�
20 2. Quantity
3, Type of system.
'F0WN 0F NOF,"NJ Ml@(�/E� Cesspool(s) f,Sgp'Lic Tank T ight Tank C.
❑MEN F
Other(describe):
4, Effluent Tee Filter present? ❑ yes 1-j yes, was'it'cl'eaned? I] ves
5. Condition of System:
6. LS',yste �mped
Nam
Vehicle License Number
StewarTs Se tic Service
Company
7. Location where contents were disposed
Stewa L s
-Rr -treatment. Ma 01835
ikure o, auler
Dace
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