HomeMy WebLinkAboutSeptic Pumping Slip - 1785 SALEM STREET 9/21/2016 _ Commonwealth off Massachusetts
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City/—I own of Noah Andover
SYste - Pumpng Record
Form 4
IDEP hastprov'ded this form for use by local Boards of Hea':h. Omer forms may be used, t
irJ;ormaiion must be substantially the same as that provided here, Before using this form, c
lacai Board of Health to determine the form alley use. The System Purnpina Record must g
the local Board of Health or other approving auLho$ity within 14 days from he pumping dal
accordance with 310 CMR 15.351,
& Facility information
Important:When
SIling out or7s I. System Location;
on'the computer,
use Only'he�A I
key to move your Address
cursor-do not
use the return North Andover
key. City/-Iowr, — �_�... .._......._. .. .
.._.-.-..._..._.. 'Z'-p Code
2. System Owner
Name_-
Address of different from location) —
State .....__� •Z;a Code
Teleohone Number
B, PUMPing Record
1. Date of Pumping
Date 2. Quantity Pumped:
LGa+ions
3. Type of system. ❑ Cesspool(s) -9e tic Tank// p � ❑ Tight Tank ❑ Gre
❑ Other(describe): ----_ ............ _..____...__._,. _.__........ .__.r_...__._
4. Effluent Tee Filter present? ❑ yes z No is yes, was it cleaned? ❑ Yes L
5. Condit'gn.�o�f�Sys em:
6. Syste P ped By:
Name
Vehicle License Number -
Stewart's Se tic Service
' Company —..._...._
7. Location where contents were disposed:
Stewari's Pre-treatment Plant, 20 So. MW Bradford, Ma 01835
Signature of
Signature of Receivm F "
Date
25tor�:-�S,doc•03!06 •
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