HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 9/20/2016 _ Commonwealth Of Masa sachusetts
Cl y I own Of Nbrt �1�adO�rer
. S -
Yst
. Primping Record
Form 4
DEP has+provided this form far use by local Boards of Health. Other forms may be used, but
information must be substantially the same as that provided here. Before using this form, Ch(
local Board of Health to determine the form they use. The System Pumping Record ;rust be
the local Board of Health or other approving authority within 14 days from the pumping date i
accordance with 310 CMR 15.351,
A- Facifily Information
Important:when
71114-1 g out forms I. System Location:
on the computer,
use only'he tab
trey to move your Address — —_._. _.._.._._._W_..-_.___._ .. .. __.__-._.._ _.. .... __ __
cursor-do not Nor=th Andover - —
use the return
key. C'sLY/Town
zip Code
2. System Owner:
Name
Address(if d'rierent from location) —
State 2io Code
Telephone Number -
B, PUMPJng Record
9. Date of Pumping _.— -~zQ_..' .- C1d
Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grec:
❑ Other(describe): --------
.....
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it,
cleaned? ❑ Yes El
5. Condition of System:
5. System Pumped Sy:
.------... —
Vehicle License Number
Stewart's Septic Service
Company --._....
7. Location where contents were disposed:
Stewart's Pre-treatment plant, 20 So. Milt Bradford, Me 09 835
Signature of Hauler
Date
' Signature of Receivingacilry -
_..
Date _
��to�4.doc•03106
sysiem Pumninn P.—M-