HomeMy WebLinkAboutSeptic Pumping Slip - 1327 SALEM STREET 9/15/2016 _ Commonwealth Of Massachusetts
= City/I own ®� Nosh Andover
m- Pumping Record
Form 4
DEP hasfprovided this form for use by local Boards of Heai,h. Other forms may be used, t
information roust ire substantially the same as-that provided here. Before using this form, (
focal Board of Health to determine the form they use. The System Pumping Record must f
the local Board of Health or other approving authority within 14 days from Lhe pumping da;
accordance with 3101 CMR 15.351.
A. Facility Infoffmation
im port,,a nt_When
5fiinq out corms 1. System Location:
on the compurer,
use onfy the tab'
keyto move your --
cursor-do not use the return North Andover
key. City/Town `--.-.....,.,.. ._....... .,.-......,.,..,-
Zip Code
2. System Own r:
Name . .._....,._ .._........ ......__...-
—---
Address(if different from location)
Crtyrowa - .-...._..-_...... ........ . _...-_......_._.._...-
State Zip Code
Telephone dumber - -----
B_ Pumping Record
1. Daze of Pumping __.1. �_....L .-. ,_ � dC/
Date Quantity Pumped:
Galions
3. Type of system: ❑ Cesspooi(s) Septic Tank
❑ i lghtTank ❑ GrE
❑ Other(describe): -____._......_.-
n. Effluent Tee Filter present? ❑ Yes No
1 w v
Yes, as It cleaned. ❑ Yes L
5. Condition of System:(�—e7,51 Cl
6. System Pumped By;
N
-IT
ame
Swehicle License Number ti Service
Company — .._............._ .
7• Location where contents were disposed:
Stewa s Pre-Lr imet- , 20 Sa. Mill Bradford, Ma 01$3)
Signature of Hauler ° -`-
-- Date'-..—._,....,......... .._..__:__ _
a Signature of Receiving f acil'ty
Date
i t5`o m4.cioc ()3106