HomeMy WebLinkAboutSeptic Pumping Slip - 90 CROSSBOW LANE 9/20/2016 _ C® ?monwea'ith OF Massachusetts
�= C'tY/I own OF North Andover
System- PUmPIng Record
Form 4 r
DEP hastprovided-this Corm;or use by local Boards of�LieaE;i1, Other forms may be used t
information must be substantially the same as that provided here. Before using iris'01-M, c
local Board of Heal'h to determine the form They use. The System Pumping Record must!
the local Board of f-lea3th or other approving authority within 14 days from the pumping dal
accordance with 310 CMR 15.351.
& Faci ty Information
Impoi,tanL:When
ng out for,.ns 1 System Location:
on the computer, �(
use only the pan LJ
key to move your Address
.._.__._.._._..—_-•----w.__.. ..._....__-------•--.,.... . _.....__.._..__.--
cursor-do no;
use the return North Andover
-
"Stata Zip code
2. System Owner.
Name
Address(if diffferent from location} —
Stale Zip code
• Telephone�iumoer .....--------_.�
B. PUMP'ing Record
1. Date of Pumping -!_-�
Ote 2. Quantity Pumped:
Gzllons
3, Type of system; ❑ Cesspool(s) V Septic Tank ❑ ight Tan: ❑ GrE
❑ Other(describe):
A. Effluent Tee Fifter present? ❑ Yes ❑ No if yes, was it cleaned?
❑ Yes L
5. Condition of Sysiern:
6. System Pum.pezf Sy
Name — —. _.___ —-.... _
vehicle License Number
Stewari's Septic Service
Company —..._.......
7. Location where contents were disposed:
Stewari's Pre-treatment Plant, 20 So, Mill Bradford_Me 01835
' signature of Hauler - •-___....__.....-_
__.....-
Signature of Receiving Facilty _
Date _
���o-lfi,doc 03fo6 -