HomeMy WebLinkAboutSeptic Pumping Slip - 20 WINTERGREEN DRIVE 9/23/2016 _ Commonwealth of Massachusetts
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City/ Of North Andover
System m Pump-Ong Record
Form 4
DEP hastprovided this form for use by local Boards of Health. Other forms may be used, but
informaLion 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 Purmping 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- Faeifi'Y Inlormati®n
important:When
filling out forms I. System Location-
or?'he compLrer. r
use only"he tab 1 1 �� �t. .•
key to move your Address -`.-..�_..-----._�.. .------�_...---........ . ......--•--..�.____
cursor-do not
use the return North Andover
key. City/Town
late Zip Code
2• System Owner:
_.— —..__
Name ._......._-.._......... _
era,•,
Address(if di"ere",from iorztion) —
State Zip Code
Telephone Number – ---
�. PUMPing Record
I. Date o;Pumping -• f6k _-1.6...... ._ 1
Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Q"'Septic Tank ❑ Tight Tank ❑ Grea:
❑ Other(describe): - ........- :... .,_..._.. ---..—__.._..__......_.....__.
4- Effluent Tee Filler present? ❑ Yes ❑ No If yes, was ii ciearied? ❑ Yes ❑
5. Condition f System:
6. Syste mped By;
° Name ---_..—.___-----... __..._..---•—�...----...Vehicle License license dumber
Stewart's Septic Service
Company �._._..... ....._ .
' 7. Location where contents were disposed:
St !art's.Pre treatment Plant, 20 So. Milt 8radiord, Ma 01835
--------•-. Ld, M ---
Sig
atur eof�r�ler
- .M
{ Date _---
_.---'
Signature of Recelving Facil''y
Da'e _
YSfo n4.dac•03106
'r
Svstem Pur:Sninn P.,,,,;_
1