HomeMy WebLinkAboutSeptic Pumping Slip - 31 OXBOW CIRCLE 9/1/2016 co
Mmonweafth of Massachusetts
CRY/Town eI Nosh Andover
Stem Pumping Record
For 4
DEP has provided this Corm for use by local Boards of,LiiealI-h, Other forms may be used, t
information must be substantially the same as that provided here. Before using iris fo-m c
local Board of Health to determine the form they use. The System Pumping Record must t
the local Board of Health or other approving authcrity within; 14 days from the pumping dat
accordance with 310 CMR 15.351.
A. Facility Wolf-mation
important'when
s;ling o{t forms 1; System Location:
on the computer, l
use only the tab
key to move your Address - ——_._._-...._._...—_..-_--_. _.. .. __._ -_..---
cursor..do not North Andover - ......."
use'he return
Zip
key. Cliyrown .._._.......... .............. � _. ---
`�tata _Code
2, System Owner:
Name —�-- — -
Address(if drff'erent from location) -
Ctyrown
State - Zip Code
Telephone Number - - -'---'
3. PUMPing Record
1. Date of Pumping _.—_... - -- .......-... +
Date 2 Quantity Pumped.
gallons
3. Type of system: [❑ Cesspool(s) ptic Tank ❑
:ighi T2nk Gre
❑ Other(describe): -- ----..........-- ,..._.
4. Effluent Tee Filter present? ❑ Yes No
If yes, was ii clean"ed? L-1 Yes �
5. Condition of System:
Cbo��r
S. System Pumped By:
Name
Vehicle License Number — —
Stewari's Septic Service
Company —..—.....
7. Location where con' Ls ere se .
Siewar's Pre-tre m i Plan` 0 ill B = rd, Ma 61835
1_w X016
re of Hauler -._.._-._-..—
Date Signature of Receiving Facirrry
Date ........—
Z5form4.doc•03!06