HomeMy WebLinkAboutSeptic Pumping Slip - 1593 OSGOOD STREET 9/30/2016 COMMOnvvealth Oa Massachusetts
City/Town of NorLh Andover
{ teml Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used,
information must be substantially the same as Thai provided here. Before using this fo,•-M, r
local Board of Health to determine the form they use. The System Pumping Record must l
he local Board of Health or other approving authority within 14 days from the pumping dal
accordance with 310 CMR 15.351,
A_ Facifiite Information
impor`ant:When
Siting out forms 1: System Location:
on the computer.
use only'he tab l s7 q3
keyto move your Address — ........
cursor-do nos __.....__.
use'he return North Andover
key. Cry�own ....... .. ....... . ...... ..:. .;. _....__..---.._..__........__...._..._.. _ _
Mate Zip Code
2. System Owner:
rdame � _..._..... .. ......--�--._.--•---- ---�---.-------
Address(if different from location)
Stzte Z.0 Code
Telephone Number -- --�
B_ Pumping Record
1. Date of Pumping
..._ ........ 2. Quantity Pump U
Dare ed;
G2llorrs
3. Type or
"system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank GrE
❑ Other(describe): -- ----......_._._...;.. __._.._,. _..
4. Effluent Tee Filter present? ❑ Yes No
// if yes, was it Gleaned? ❑ Yes I�
5. Condition of System:
6. Sys° "dumped By:
Name __._..._.—.------.__.._
Siewa .s Se iiC SerVIGe vehicle License'Number
Company —..._....... ..._
?. Location where contents were disposed:
Stewart's Pre-treatrnent Plant 20 So. Mill Bradford, Ma 01835
Signature
Date .... .
Signa�.ture of Receiving Faciir�j
Dace
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