HomeMy WebLinkAboutSeptic Pumping Slip - 39 HAY MEADOW ROAD 9/16/2016 _ ® . monwealth O' Massachusetts
❑fty/®vein ®� Nosh Andover
PuMPIng Record
Foils'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 ;sing this form, (
local Board of Health to determine the form they use. The System Pumping Record must i
the local Board of Health or other approving authority within 14 days from the purnping dat
accordance with 310 CMR 15.351•
A. Facifiity Inf®li^rnation
Important When
5111419 out forms 1. System Locati n:
On'he compu<er.
use only'he tab
Key to move your Address 1� --••-------....__.. M._....._._..__... . ..
cursor,do no:
use the return North Andover
—°--
key. Cittyrovusi ,..._............. .......... ..... �� --�......_...._.-._., — _-
"Jiaie Zip Code
2. System Owner:
J � Name ._......__..._ ....... ......-- -•----------••--.___.—.___-�—
Address(if d�'erent-from location)
CFyrown
Slate �i�COdE
Telechone Number
�. Pumping Record
�. Date of Pumping
_.— ..._.__.... -- ......_ . 1
Date .... .._ 2. Quantity Pumped.
Gallons
3. Type Or'system: ❑ Cesspool(s) Septic Tank
❑ T Ight Tank ❑ GrE
❑ Other(describe): ---_-• .-.....-..... ........_-----..__._..-_._...... . .__.__..--_._
a. Effluent Tee Filter present? ❑ yes ❑ No If yes, was it cfean'ed? ❑ Yes L
5. Condition of ystemn
S
3. Sys°ern�P1umped By:
Name — `�. - —._....• _
Vehicle License Number _
Stewa Cs Se tic Service
Company �_._...._.._..._
7. Location where contents were disposed:
Zsitelw_v Pre-t[eatment Plant, 20 So, Mill Bradford, Ma 01835
fd
Date
Signa—Lure of Receiving Facilry -
Date.._...._-.._ ..,......._._ .. . ..-._._.._�.
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