HomeMy WebLinkAboutSeptic Pumping Slip - 36 SHANNON LANE 9/18/2016 Commonwealth of Massachusetts
_ Cay/I own Of Nosh Andover
SY Ste M- Pumping Record
Form 4
DEP hastprovided this igrm for use by local Boards of Health, Other forms may be used t
imbrmation must be substantially the same as that provided here. Before using this form, c
local Board of Health to determine the loan-hey use. The System Pumping Record must F
the focal Board of Health or other approving authority within: 14 days from the pumping dal
accordance wrh 310 CMR 15.351,
A. Faciiiy information
Important:When
Slljng out;oris I. System Loca Ion:
07 the computer,
use only the tao
key to move your Address -
cursor,do not
use the re-,u-,n North Andover
key. City/Town _......_. . ......i...._..,."..:-
Zip G06E
a
� 2. System Owner.
} Name _......_..._........ ......__. .._._ -- - --- - —
Address(if deferent from location}•� ...... .... . ..." ..-.
Crown -- ._...._..
Sate Zip Code
Tefeohone Number �"�_._.._._....,._.
R Pum Pil>�� Rey®��
1. Date of Pumping -.�J.. �.�. .,.... ._ �a
Date 2<SeLic Quantity Pumped.
G2llons
3. Type of system: ❑ Cesspool(s) T a nk ❑ T ighi T an-x ❑ Grs
❑ Other(describe): ------- ....:_.... _._..._.. -..._.�- -...__._._ -........
4. I~s:luent Tee Filter present? ❑ Yes No es, was ti clt-aned? ❑ Yes L
5. Condition of System:
C
6. System Pumped B '
Name
Stewa s Se tic Service Vehicle License dumber - —
Company —.-. ....
?. Location where contents were disposed:
Stems`Pre-treatrneni P nt o. Mill Bradford, Ma 01835
Signature o Hauler --` - --
Da2e _ —... ............ . ..__..-. - -
9 Receiving Facilty ." _..- _.-
Oaie
2510-14-doc•03/06