HomeMy WebLinkAboutSeptic Pumping Slip - 42 TANGLEWOOD LANE 10/28/2016 RECEIVED'
NOV 14 ?()16
Cornm' on
wealth Of Massachusetts
TOWN O�NOR 1 H ML)OVER
City/ I own o-I" North Andover HEALTH DEPARTMENT
System- Pumping Record
S li-ono 4
DEP has provided This form for use by local Boards of Health. Other forms may be used t
information must be substantially the same as that provided here. Before using this foFm,
local Board ofFlealth to determine the form they use. The System Pumping Record must I
the local Board of Health or other approving authority within 14 days from the Pumping da'I
accordance with 310 C MR 15.351
A- Facility Wormation
Important When
filling out Torrns 1'. Sys-Lem Location:
on'the comput ter,
use only the tab
key move your Ad ress
cursor-do not
use the return North Andover lJ
key.
2, System-Owner-
Name
Address(if d'rf;erent from location) -
state Zilo Code
...........
Telephone Number
Purnpilng Record
-�
W,
I. Date
Of Pumping
Date Quantity Pumped:
Gallons
A
3. Type of system:
Septic❑ cesspool(s) Tank ❑ fight Tanx Grp
❑ Other(describe)-
4. Effluent Tee Filter present? El Yes �No yes, was iz Cleaned? 0 Yes
5. Condition of S
6.a_y
Stewart's Septic Service Vehicle License Number
OMP2ny
7. Location where contents were disposed:
Ste_ wart`s„Pre-tr atm nt Plant, 0. Mill Bradford, Me 01835
Signature QfHauler
Date _.,__._-
Signature ...... . ........
Da'te
k5forr.14.doc-03106