HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 9/13/2016 Commonwealth Of Massachusetts
C
Ityl I own af Nortih Andover
stem m- PumPing Record
€-Orm 4
DEP has"provided ''his form for use by local Boards of Heal:h. Other forms may -be used, t
information must be substantia[lythe same as that provided here, Before using this 7-0)-m
local Board of Health to determine the form they use. The System Pumping Record must
the local Board of Health or other approving 2Uth0i-*within 14 days from the pumping dai
accordance with 310 C M R 15.351.
A- Facility Information
lmpo;lan',When
liffing outforins I' System Location'
on the computer, 17 1
use only the,ab r-/ . 1A I f JI/I
key to move your _Address 'I'
cursor-do not
use'the retum North Andover
key.
state Zip codE
2. System Owner-
ame
Address(if dif-T erent,fromiotionj_-
FIT .
Siaie ........
Zip Code
PUMP ng Rec
I. Date of Pumping 2 Quantity Pumped: C-,C)
Date
Gallons
3. Type of system. ❑ Cesspool(s) ❑ Septic Tank
❑ Tight Tank ❑ G,-E
❑ Other(describe):
4, Eff luent Tee Filter present? ❑ Yes 0 No f yes, was it clear�ed? ❑ Yes
5, Condition of System:
6. System Pumped By:
Szewar'Cs Septic Service
Vehicle License Number
Company .......
7. Location where contents were disposed:
-Stewart's Pre-treatment Plant, 20 Sc• ML111 Bradford,Ma 01835
Signature .......
Date.
Signature we&Receiving Facil"rtij -
Date e
03106