HomeMy WebLinkAboutSeptic Pumping Slip - 651 TURNPIKE STREET 9/23/2016 _ Cornm' onweafth ®a Massachusetts
=
City/ own of North Andover
System. Pumping Record
Form`4
DEP has provided this;orm :or use by local Boards of Health, Other forms may be used, bu-
information must be substantially the same as that provided here. Before using this form, chi
focal 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. FaeA>iy Infog-mat10 n
Important:When
'Sliing out forms 1. System Location: {�
on the computer, t( 1 1 1
use only the tan `
key to move your Address --—_._. -._ ..._... __.._._.M.__.
cursor-do not
Use the return North Andover
key. City[Town
Male Zip Code
2. System Owner•
art
_.—
a Name
_.-----°------..—.___.--
Address(if different from location) - - • ' -
Stale _
Zi._.a_.Cod—e.
Teleohone dumber
�. PUMOng Record
1. Date of Pumping -.M 7L _� •_., �
Date 2. Quantify Pu ped:
Gallons
3. Type of system: ❑ Cesspooi(s) epiic Tank El ighi ank ❑ G1ea:
❑ Other(describe): - ._....___....._...._.._.. - --...- -........ ._.. .... -
4. Effluent Tee l=itter present? ❑ Yes
if yes, was if cleaned? ❑ Yes
5. Condition of System:
6• System Pump By:
Name
Vehicle License Number
Stewaffs Septic Service
' Company _._..... .
y. Location.where contents were disposed:
S`ewarts Pre ` at i Plant, 20 So. Mill Bradford, Ma 01835
Signature of ler
Date _..- - -
Signs— lure of Receiving Facilsy
Date
Z&O.-M4.doc-owo6
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