HomeMy WebLinkAboutSeptic Pumping Slip - 304 BOXFORD STREET 9/12/2016 cityrown ®f North Andover
System Pumping Record
= � For'
DEP has provided this form for use by local Boards of Health. Other forms may be used, but
information must be substantially the same as that provided here. Before using this form, the
local Board or'Health to determine the form they use. The System Pumping Record must be
the local Board of Health or other approving authority within 14 days from tz`1e .pumping date i
accordance with 31C CMR 15,351.
A- Paci lfty 11"ormation
Important_When
5111n9 out fours I. System Location:
on the computer.
use only'he tab Y
key fo move your Address � `--- -
cursor-do not _. --
use the return North Andover
key.
`Mate Zip Code
2. Sys` m Owner: t,
Name I
Address(if differeni from location)
State__..._.--•---^.—......._.. ----•_...-
Zip Code
Telephone Number _.._..----•---
�. Pumping Record
�. gate o;Pumping �� ❑�: .......... 2. Quantify Pumped.
Date �.......
Gallons
3. Type of system: ❑ Cesspool(s) 9/Septic Tank ❑ Tight Tank ❑ Grea:
❑ Other(describe); ----__..-........,_._:..__..._..._..�___..—_._..__.__....... ....__._ ..._.._
4. Ef fluent Tee Filter present? ❑ yes ❑ No If yes, was it cleaned? �
❑ es
5. Condition of System,
d t' -
6. Syst m Pumped 8y:
Name
Siewa Vehicle License Number l
ri's Se tic Service
Company —
7. Location where contents were disposed:
Stewart' re-treatment-P 20 So. Mill Bradford, Ma 01835
signs, of ude - v
Date -.. -- -
SEgna-~^ pure of Receiving Facil'r�ry
Date
iSfo4.doc 03106
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