HomeMy WebLinkAboutSeptic Pumping Slip - 1267 OSGOOD STREET 10/7/2016 Commonwealth Of Massachusetts
� r�or � OF North Andover RECEIVED
System- Pump-ng Record NOV 1 ?x)16
= 4 For 4
TOWJ q o flr `-r ANDOVER
LDEP haslprovided this form for use by local Boards of Healhl Other form smay be used, t
information must be substantially the same as that provided here. Before using this form
local Board of Heath to determine the form they use- The System Pumping Record must!
the Coca Board of Health or other approving authority within 14 days from the pumping dal
accordance with 310 CMR 15.351.
A- FaciO 4 Wormation
Importarit_'When
suing out forks 1; System Location:
OP the computer,
use only the tab /
key to move your Address G ----.--
cursor-do not
use the retum North Andover
key. Crtyrow•n _........ - __ __..__.-.....__......
Mate Zip CodE
2. System Owner:
Name _....___.. .._....... ........... ......__. .....______..
Address(if dffferent from Io(2tion) -_
State Zip Code
Telephone Number
PUMP'ing Record
I. Daze of Pumping A- -- 7--/tU t�C%U
2, Quantity Pump mod:
Da'e
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight F an-k ❑ GrE
❑ Other(describe):
4. Effluent Tee Piiter present? ❑ Yes eNo
{f yes, was ii cleaned? ❑ Yes
5. Condition of Sy `em:
6, Sysle2f Pumped B
Name _.
Vehicle Lic—en se Number -
Stewari's Septic Service
Company _,.._.......
y. Location where contents were disposed:
Stew. s P e-treatment Plani�.20 So. Mill Bradford, Ma 01835
I � �
Signature of Hauler
Date
Signature of Receiving
'y 62. .
Zy'0, 4.doc•03106