HomeMy WebLinkAboutSeptic Pumping Slip - 59 WILLOW RIDGE ROAD 10/19/2016 Com
monwealth Of Ma sachusetts
City/I own OF North Andover RECEIVED
. SYStern Pumps Record
= Gov � u
TOWN OF NOR FHANDOVER
DEP has provided this form for use by local Boards of Health. O
information must be substantially the same as that provided here. Before using this for M,
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 the pumping dai
accordance with 310 CMIR 15.351.
A. Facility info rmation -
Important:When
15 11in9 ourforns 1: System Location: R
on the computer, -may \,
use only the tab "__. ,i{ _..-1 �yp�✓ 1 J
key to move your Address _..__,._....._..,.__... . ..
cursor-do not
_..
use the return North Andover
key. c��tyrow„ ... . .......................y _,......,_. __
Laze Zlp rodE
2. Systemrr Owner-
7N
ame
_.
Address(if different from location)._......_. '.,.
ctyrown .--___._...._................ ..
State
Zip Code
Pump ng _- m'eleohane NumNumber
�. Rec•ord f -
1. Date of Pumping �..._1�_4�----��
Date 2. Quantity Pumped:
L Gallons
3. Type of system: ❑ Cesspool(s) Septic _!ank ❑ Tight Tank (❑ OrE
I
❑ Other(describe); — _._---_.....,._.,..__......_...__.._..�___...__..._...__.......
4. Elmuent Tee Filter present? ❑ yes [) No If yes, was it cleaned? ❑ yes L
5. Condition of System:
6. Systemt Pu ped By:
Name
-SA e-w art'S Septic Service Vehicle license Number - — —
Company _ _..,..
?. Location where contents were disposed:
thwart` Pre-tr c ent Plant, 20 So, Mill Bradford, Ma 01835
Si nature-d Hauler —.,____..___•....--_-_..., _. o LO
.. . ...
Date 4•
i Signature of Receiving Facility .. .. .
Date
2jf0.n4.doc•03/06