HomeMy WebLinkAboutSeptic Pumping Slip - 316 CANDLESTICK ROAD 10/5/2016 Cornaionwealth O Massachusetts
- mown of North Andover
. -.SYstem Pumpgng Record RECEIVED
Form 4 •
-
O 1 Irl 2016
DEP he this Dorm for use by local 9 ?: 1florms may be used,
information must be substantially the same as ti ,M\JdRO�)MNTBefore using this ioiT:'1, �
local Board of Health to determine the form they use. The System Pumping Record ;~gust 1
the local Board of Health or other approving authority within 14 days from the pumping dal
accordance with 310 CMR 15.351.
A. Facility Information
important:'When
5liing out forms 1. System Location:
on the computer,
use only the tab , .) , ' /
7
key to move your
cursor-do not
use the retum North Andover
key. C`r,Y/–,O_ _
ZipYCod@
2. System Owner:
Name
Address(ifd4�erentfrorn lacation)...� . ._ . .. . ._ ....
Stale Zip-Code
Telephone Number
R. P�Ir�g Record
1. Date of Pumping r
Gate _.._._..____........ .... 2 Quantity Pumped.
Gadlons
3. Type of system: ❑ Cesspool(s) ( Se uc T Tank� ' ` p�. ❑ Tight Tank ❑ Cry
[]
Other(describe): —.__,____,.,......._...,..._...,_..._,.____...__.,.._..__.,..._
Q. Effluent Tee Filter present? Yes (_] No If yes, was it cleaned?
,. Yes �-
5. Condition of System:.
6. System P F,f d By:
Name ---.—.____.---------
Vehicle License umber l �----
Stewar i s Septic S rvice Number
Company _..._.,...,
?. Location where contents were disposed:
Ste art's Pre-treatment Plant, 20 So. Mill Bradford, Me 01835
Signature of Hauler -- __.,..-
Date
Signature of Receivingacflc y V ' '" "
Date
15fOn-n�'.,.doc-03/06