HomeMy WebLinkAboutSeptic Pumping Slip - 225 BRIDGES LANE 10/3/2016 Comm' onwealth Of Ma,,§sachusett�ECEIVED
city/ I—own Ulf North Andover NOV 14 zow
-SYst m- Pumping Record TOWN OF NOR'[11 ANDOVER
Forrn 4
HEALTH DEPARTMENT
DEP has,'provided this farm for use by local Boards of teak h. Other forms may be used, t
information must be substantially the same as that provided here, Before using iris form, I
local Board of Health to determine the form they use. The System Pumping Record must!
the local Board of Health or other approving authority within 14 days from f the pumping dai
accordance with 310 CM R 15.351.
1 t
A. Facility wormation
Importan'-When
I
51fing out fornns 1. System Locatior
on I ,L_
the computer,
use only the tab
key to move your Address 7= .........
cursor-do not
use the return North Andover
key, Zip CodE
2 System Owner:
-dame
Address�if ,erer,from location)
Z,ffo-n
r State '2'-i p-,Cade
*
———---------
Telephone Number
Pumping Record
1. Date of Pumping ��te,
2. QuanL'ity Pumped:
3. Type 0-Isystem:
❑ Cesspool(s) ,,Z/Septic Tank ❑ -:"ight T2nk ❑ GrE
El Other(describe):
4
Effluent Tee Filter present? ❑ Yes ,E No
if yes, was itcl"eaned? Yes
5. Condition of System:
6. -y§tern-Purled By:
Vehicle License'-N-'um'b-e-r-
Stewar'L' Sseptuic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So, Mili_Bradford, Ma 01836
Signature of Hauler
Date ,
Signature of Receiving Facility ._ . ._ . .
Date
k51o.m4,doc-03/06