HomeMy WebLinkAboutSeptic Pumping Slip - 30 OAKES DRIVE 10/20/2016 Commonwealth �� A�Massachusetts �����
�����l�l��[l\�����'u / ��/ /v^����������/ /�j��n^�*� w�������m �����
City/Town of .No Andover NOV 14 2016
System Pumping Record
TOWN O�NUH[HANDOVER
Form 4 H640HDER4KT(VGNT
`
OEP has provided this form for use by local Boards of Health. Other forms may be uoed, but the
information must he substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310CK8R1S.351.
A. Facility Information
Important;When
filling out forms 1. System Location:
on the computer,
use only the tab
key t^move your awrvoo -
cursor do not
use the return ----------------
City/Town State opcnd�
_'.
2. System Owner:
- /A - - , - - --- ---------------------------
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
/6'
1. Date ofPumping - ~~~' tity Pumped:
/ _5
Date Gallons 3. Component: [l Cesspool(s) Septic El Tight Tank Fl Grease
T
rep
[] Other(describe):
4. Effluent Tee FNterpresent? [] Yes ET,No |f yes, was it�eanad? [] Yea [] No
5. Dbnemndcondition nfromp t u U
"
(Je-(- V eh i cl e Lic ense Number
Stewarts Septic 58 So Kimball St radford Ma
Company
7. Location where contents were disposed:
20 so mill�-s radfor ma
��ra-o-f'o
h facility receipt) D ate
Signature of ke—ceiving Facility—(or attac
mmm14.oc*^11/12 System Pumping Record^Page 1 m1