HomeMy WebLinkAboutSeptic Pumping Slip - 39 SPRING HILL ROAD 8/24/2016 Commonwealth oflfiassachusetts
bftth Andover
City/oven own of N A
System Pumping Record
DEP has provided this form for use by local Boards of Health. Other forms may be used, t
information must be substantially the same as that provided here. Before using this form,
local Board of Health to determine the form they use. The Systern, Pumping Record must!
the local Board of Health or other approving authon-y within 14 days from the pumping d2'
accordance with 310 CMR 15,351,
A- Fact ty Wormation
lmpoitant:'When
siting out forms I System Location,,
on the computer,
use on '_ -j
key to move your ......
Address
IY'the'2b ✓ Is
cursor-do not
use the return North Andover
key. Zip'60-d-f
2. System Owner-
Name
Address(if d-Hfferen',from'-
State 2;0 Code
I elePhone Number
I'VE'D P"MOng Record
I Date Of Pumping
Date 2 Quantit y Pumped:
Galions
MXWER 3, Type of system:
MEY q I ❑ Cesspooi(s) [A5
eptic Tank ❑ Tight Tank [I GrE
❑ Other(describe):
4. Effluent Tee Filter present? Yes [Ej"'Nio if Yes, was ii cleaned? ❑ Yes L
5, Condition of System:
6. S' yste 7 pum IM By:
Na e
Stewart's Septic Service Vehicle License Number
Company
7. Location where contents were disposed:
at
ent
, Plant, 21 So. Mild Bradford Ma 01835
VSigtwe
Date
�gnature of Receiving F
aciiity Date