HomeMy WebLinkAboutSeptic Pumping Slip - 480 SHARPNERS POND ROAD 9/18/2016 _ Commonwealth Of Massachusetts
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City/ of Nbrith Andover
m- Pumpng Record
Form
DEP h�Slprovided this form for use by local Boards of Heai;h. Other forms may be used, 1
information must be substantially the same as that provided here. Before using this form, 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 dat
accordance with 310 CMR 15.351.
A. Facility information
important_When
5iling out forms 1: System Location:
computer,
use
use only the�b _
key to move your Address
cursor-do not
use the retum North Andover
—_ __ .--
key. C't�yrown ....... ....................r.
atat Zip Code
2. System Owner:
q-r/-
Ad d'ff rent from 1 C2tiorjJ — _...._................. ..-.
Sa.e Zia Code
Telephone Number - ---
PUMPing Record
1. Date of Pumping ......
Date 2. Quantity Pumped.
Gallons
3. Type of system: El Cesspool(s) Septic Tank ❑ ;ight Tank ❑ Cr e
❑ Other(describe): - - _..._..- _.. ---..._ - _........ .. ... .._ ._
a. Effluent Tee Piker present? ❑ Yes No v
If yes, was it cl'eanwd? ❑ Yes L
5. Condition of System:
6. System Pumped By:
Vehicle License Number —
Stewari's Se tic Service
company �..._...
y. Location where contents were disposed-,
XS-te� a s re-ir atrrlent P t 20 Sg. Mill Bradford Ma 01835
gnature of Hauler --" ---- ..
Date ,
u Signature o`Receiving Facility
D2te
16`0-4.d0c-03106
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