HomeMy WebLinkAboutSeptic Pumping Slip - 47 BOXFORD STREET 9/22/2016 _ Commonwealth Of Ma5sachuse s
= C y/T own ®i Nor�h Andover
System m Pumping Record
Form 4
DEP hasl'provided this form for 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 must 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_ �a��l� ft, ormafio a
Important:_-When
51IN g out`ours 1. System Location:
on the compcter• L
use only the tb
key to move your Address _...._. ___.__.
cursor-do not North Andover
use'he return
key. C'YyTown
atate Zip Code
C 4
2, System Owner:
Name —� `--
Address(if d"s�erent from location)•� - - '" - •- .._..
State Z e
P-,Cod
' TeleohoneNumber .._...._._-.,...._.
B. Pt�&a�Ping Rec®Irk
1- Date o;Pumping Da e -4> 2 Quantity Pumped:
Gallons
3. Type of system; ❑ Cesspool(s) Septic Tank ❑ Tight 1 an'.k ❑ Grea;
❑ Other(describe): ------- ........ .......- ._..._._ ---.._ _._..__._........_.... ..__.._ ._
4. E:f luent Tee Filter present? ❑ Yes 9-ITO if yes, was it cleaned? ❑ Yes
5. Condition of System:
3- System P d By.
Name
Vehicle License Number l
Stewa Cs Se c Service
---_
Company ..._...._. .._...
7. Location where contents were disposed:
Stewarts Pre-tr Lmeni PI t, 20 So. Mill Bradford
—M.a 01835
Signatu e of Hauler Y-.__-_....--....__.._._... . _
te
..
Da .---•-- -
Signature of ReceivingaGil'ry
Date
t3forn4.doc•03106
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