HomeMy WebLinkAboutSeptic Pumping Slip - 1797 SALEM STREET 9/21/2016 Commonwealth ®f Massachusetts
City/ ®vin o North Andover
Systern Pumping Record
Form 4 r
DI=P h'aslprovided this form tar use by local Boards of Heai;h. Other forms may he usea, t
information must be substantially the sarne as that provided here, Before using this- c
local Board o;Health to determine the form they use. The System Pumping Record must F
the local Board of Health or other approving authoi7ty within 14 days from the pumping dat
accordance with 3103 CMR 15.351.
A. Facility Information
Important when
111ing oLrt forms 1: System Location:
on'he compLrter•
use only the lab
key tto move your Address '
cursor-do not
use the re2u n North Andover
key. awn �..._............ ....
�taie Zip Code
2. System Owner:
Address(if dif Brent from location)
Siaie rZip-Cade
7eleohone Number -.. _.._..—.--•--._____
PUMping Record
I. DateofPumping _. ... �❑ .. ....._._
. — Date � 2, Quantify Pump°d: 011�1111
3. Type of system, ❑ Cesspool(s) Septic Tank ❑ Tight E ank ❑ Gre
❑ Other(describe): — _ ......_._...;...----_.._..
4. E'luent Tee Pilfer present? ❑ Yes &No 1;yes, was ii cleaned? ❑ Yes L
6. Condition of Syste
6. System Pu d By: i
Vehicle License Number
Stewart's Se tic Service
Company _............._ . ..._ .. _
�• Location where contents were disposed:
Stewari's Pre--treatment Plant, 20 So. Mill Bradford, Ma 01838
signature o`
Date ,
Signature of Receiving F cifr<]r
Date
��o-�S.doc-03106