HomeMy WebLinkAboutSeptic Pumping Slip - 311 DALE STREET 9/30/2016 ® M®nweafth Of Massachusefts
Giiyfown Of Nosh Andover
ystem Pumping Record
FOB 4
DEP has provided this form for use by locaf Boards of Health, Other forms may be used r
information must be substantially the same as that provided here. Before using this fo;-M' ,
local Board of Health to determine the form they use. The System Pumping Record must 1
the local Board of Health or other approving aui7o-iy within. 14 days horn uhe oumoing dal
accordance with 310 CMR 15.351.
A_ Facility InfOrMation
Important:When
51fingoutforms 1'. Systern Location:
on the computer.
use only'he tab
key to move your Address __ - — _----
cursor-do not
use the return North Andover
key. GFtyilown ....................: ..,.. _._.__.._._......_.. .._,. _ __
SJidiB _. zip CodE
2. S'y{stte n Owner; '
z Name �_ —._,. .._....,.._..._
Address(if different from location)
State Zia Code
Tele.ohone tNurnber ..._._.._.._-,_..._.�..
R PurnOng Record
I. Date of Pumping --=f~ _. _ 7 .._ � �
Date 2. Quantity Pumped;
Gallons
3. Type of system: ❑ Cesspool(s) Kseptic Tank ❑ Tight Tank ❑ GrE
❑ Other(describe):
4- Effluent Tee Filter present?
❑ Yes kNo I.yes, was it cl'earted? ❑ Yes
5. Condition of System.
5. System Pumped By:
Name
Vehicle License Number
Stewar;'s Se tIC SefV1Ce
7. Location where c rVten` were pose .
Stewar's Pre- l i, 20.S _Mili Bradford, Ma 01835
Signature of Hauler
Date -' --
S"tgna�4ure of Receiving i a�i!'
Date
t5forrn4.doc•03106