HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 9/27/2016 _ C orn monwealth ®s Massachusetts
- ; CjiY�®wn ®f Nbrth Andover
SYstem_ Pumpgng Record
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DEP has provided this i0rm for use by local Boards of `seal'h. Other forms may be used r
information must be substantially the same as that provided here. Before using this T'01-M, c
local Board of Health to determine the form they use. The System Pw-nping Record must!
the local Board of Health or other approving authority within 14 days from the pumping dai
accordance with 310 CM 15.351.
- Facility Information
Importance When
frlIing Litt form,s 1. System Location:
the computer,
us
use only'he tan
key to move your Address "" -
cursor-do not North Andover
use the return
_ ..._.,_....
key. C$yown —_ --_
_ estate Zip Code
2• System Owner:
Name _ _�l X_.
Address(if d'Fferent from location} —..,...................
State..._._.._.._,._..�.....__W.. ._._.—.
ZiP Code
Teleahone cumber
1. Date of Pumping -•---. _' 7 .( � ��
Date
2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ `fight T ank ❑ GrE
❑ Other(describe): --- ....._,_ ....- .._..._.. - -..__._._,.__...... . -
A. Effluent Tee Filter present? [❑ Yes ❑ No If yes, was it cl'ean:a? ❑ Yes I
5. Condition of System:
6. System Pumped By;
Vehicle License\umber —
Stewv Cs Se tic Service
Company _..._............._ .
�• Location where contents were disposed:
Stewarts Pre-treatment Plant, 20 So. Mil! Bradford, !Via 01835
Signatureotiauier
Date -- --
S:gnawre of Receiving Facij�Ly
Date M�
'i
t5fo.-,4.doc•
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