HomeMy WebLinkAboutSeptic Pumping Slip - 75 TANGLEWOOD LANE 9/23/2016 _ Commonwealth ®a Massachusetts
9 Citr/—1 own ®f North Andover
System. PuMpEng Record
d=orm 4
IDEP hasfprovided 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 fora, Ch(
focaf 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 CM 15.351.
A_ Faeilliy lnfor atj()n
Important.When
Sling our,;orms �. System Location:
on the computer. 1 f
use only the tab L
key to move your Address - —_._.__._...._...__..._._--._-..
cursor-do not
use the retum North Andover
key. C'V-1 own —_- -
`Stata Zip Code
2. System Owne
to Vb
I.fIf
aName 5.�� -..__ .._......._..._......... ..... _. _.. -
Address{if d'�erent from location} - •� ��
SiatE 'Z'-i Code
TefeohoneNumber -...__.._..----•--.
B. Pumping Rec ord
Date of Pumping -bate
4 ...- - .. -- _......... 2. Quantity Pumped:
Gallons
3. Type o,system: ❑ Cesspool(s) Se tic Tank p ❑ fight Tank ❑ Grea<,
❑ Other(describe): _ - ..._. --......_.. -.._.. _- -,..__._.._.._......._•. -
4. Effluent Tee Filter present? ❑ Yes if yes, was it cleaned? ❑ Yes
S. Condition of System:
6.
System P u ped y
N
Vehicle License Number
Stewart's Septic Service
7. Location where contents -d'
S`ewari's Pi' -treat ern last, 20 So. Mill Bradford_Ma 01835
1 �— �
Sigaatureo; auier - ---....__.....----.-..-
- - --- --�
Date ,
Signa ure of Receiving Facilr�-
Da _.._.........
• to .._.._._..._... . . •._..._...
t,5'0.'m4.doc•03/06
Svstern Pumninn
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