HomeMy WebLinkAboutSeptic Pumping Slip - 537 BOXFORD STREET 9/12/2016 CO
rnmOnwealth Of Massachusetts
Giiy/Own 08 Nb th Andover
Stem- Pumping Record
mii-;a' 4- .,
LDEP h`as,provided this form for use by local Boards of `-ieal,h. Other Corms may be used, t
information must be substantially the same as that provided here. Before using this fore, c
local Board or Health to determine the form they use. The System Rut !ping Record must N
the local Board of Health or other approving au-U;Ority within 14 days from the pumping da;
accordance with 310 CMR 15.351,
& Faeifity information
Important_When
Illing out forms 1: System. Location:
orr the comptrter.
use only'he tab A
key to move your Address
cursor-do not
use the retum North Andover
key. C"ryrown — — --..._ ......-.. .. .
State Zip Code
2. Systern Owner-
Me
Address(if d'femni from location) —
State.._._.._.._....—._........
_. Zip Cade
Tefeohone Number _.._..-.--•_-.
�. Pumping Record
Dale of Pumping
-. _...- ---................._
2" G21fon
Date Quantity Pumped: -
• 3. Type of system: ,.1, s
❑ Cesspooi(s) El Septic Tank ❑ Tight Tank ❑ Gre
❑ Other(describe):
4. Ef f luent Tee Filter present? ❑ yes [] No If yes, was ii cleaned? v
❑ es L
6. Condition f System;
6. System Pumped By:
Name
SewS Vehicle Lcense Number
c ervice -
7. Location where contents were disposed:
Z Ste k's Pre-treatment Plant, 20 So. W1 Bradford, Ma 01835
Signakure r __:::_
Date
Signa---. pure of Receiving Facilriy •
Date
LS1o�4.doc-03106