HomeMy WebLinkAboutSeptic Pumping Slip - 210 RALEIGH TAVERN LANE 9/15/2016 _ ®mmonwealth Of Massachusetts
City/Own Oi Nor kh Andover
.system Pumpng Record
4
DEP h'as�provided this form for use by local Boards of Health. Other forms may be used, t
information must be substantially the same as that provided here. Before using this,orm, c
local Board of Health to determine the form they use. The System Pumping Record must t
the local Board of Health or other approving authority within, 14 days from the pumping dpi
accordance with 310 CMR 15.351,
A. Facility Information
impor°zani:when
5liing out forms 1- System Location: 1
on the c Theta r,
use only the two
key to move your Address -' -T(I "
cursor-do not
use'he return North Andover
key. --siy/Tovan ........,. .,. --- -------..._..__.....---•--.... - ---
` ta e
, .Zip Code
2. System ner-
ame — ------ -
Address(if d' lo
ere from c2ti0n)
State Zip Code
Telephone Numoer -.. .„ ._
�. Pumping Rec'Ord
I. Date of Pumping _.�.. _�. _..,. ..._
Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) El Septic Tank ❑ ?ight Tank ❑ Gre
❑ Other(describe):
a. Effluent Tee Filter present? [] Yes E No If yes, was it cleaned? ❑ Yes E
5. Condition of System;
6. sy t Pumpe By:
�c
r
Name — _._. -- —.....
VeTicle License dumber
Stewari's Se tiC SeNiCe
Company �...-........_..._
7. Location where contents were disposed:
Stewart, Pre-trea'p ent Pla , 20 Sc). Mill Bradford, Ma 01835
._.!
r
Signature of Hauler �-"--`_...._„___,.•„,
Date - ----
Signature of Receiving Facilr=,y
Date
ZJ10-4.doc•03!06