HomeMy WebLinkAboutSeptic Pumping Slip - 73 CHRISTIAN WAY 10/5/2016 RECEIVED
Commonwealth O' Massachusetts
C ltyf— -z Nbriffi Andover NOV "14 Z( Iii
I own ol
System Pumping Record TOWN OF NUI-� HANDOVER
. ...... .... Form 4 -
HEALTH ter PARYMENT
form rM to P has this' for use by local Boards of Heah,'h, other or rns may be used, 1:
information must be substantially the same as that provided here. Before using this T-01-M, (
local Board of Health to determine the form they use. The System Pumping Record rnust!
the local Board of Health or other approving authority within 14 days from The pumping dal
accordance with 310 CMR 15.351.
A- Facility lnformation�
importan':When
51fing oLl"for,ns 1. System Location:
on the computer, (5 '' Cha
use only the tab
key to move your Address
cursor-do not
use'the retum North Andover
keyk city)own own
,
Zip Code
2. Syst Arn owner:
�o fr
Name
Ciftyff own -------
S ate Zip Code
Telephone Number
Pumping Record
1. Date of Pumping
Date - 2, Quantity Pumped: C60—
Gatfons
3. Type of system: ❑ Cesspool(s)
E tic Tank EJ i ight Tan: ❑ GrE
Sep'
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? f—I Yes L
5. Condition of System'
6. -------------
Sys-
Name
Ste
wart's Septic Service—..- Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill_Bradford, Ma 01835
Signature
of Hauler —� "----"'----
�re
Signature of Re .....
Date
t�'fo'm4.doc 03/66