HomeMy WebLinkAboutSeptic Pumping Slip - 350 FOREST STREET 9/7/2016 COMmonweaith ®� Massachusetts
❑ y/1 own Oi North Andover
stem- Pumping Record
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BEP has provided This form for use by focal Boards of ;eal h. Other i"orms may he used, r
information must be substantially the same as that provided here. Before using tNs fo,-m,
local Board of Hea€th to determine the form they use. The System Pumping Record must
the local Board of Health or other approving authcriy within 14 days from-the pumping dG
accordance with 310 CMR 55.351.
A_ Facility Information
impo;,aFit When
5llingou;forns 1. System Location:
use only'he�b 7) p — s-
key to move your Address "' -
- _.-
Ur50f-do not
use the rep,;; North Andover
key. C'tyrowM — —�--
`Stata - ....... Zip Codi
2. System Owner:
Name
Address(if d'r`erent from location) _
S ate Z:p Code
Tetephone\umber -
�, PUMOng Record
1. Daze of Pumping ' �?
... � '-
Date 2 Qu2ntity F'umpea:
Gallons
3. Type of system: ❑ Cesspool(s) epiic Tank ❑ Tight T2nk
❑ Gf f
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye loo
!f yes, was r cleaned? ❑ Yes�y ',
5. Condition of System:
S. System Pumped Bye
Name --°---,•.—_...--..------ _ _
Ste Wal i s Se tic Service Vehicle License\umber
CornPany —...—..... ......_
7. Location Where were p os
Stewart's Pre ` r�` L, 2 0. Mill Bradford, Ma 01835
Signature o,Hauler
SI19 2 Ure Of Re—celving
Date _
t5forn4•doc-03!06