HomeMy WebLinkAboutSeptic Pumping Slip - 755 JOHNSON STREET 10/19/2011Important:
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be 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 7yo.e ,„§whruitted-to--
the local Board of Health or other approving authority within 14 days from the purriping dtejn::;fl,a,:D
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
,C1(1
Address
No.Andover
City/Town
2. System Owner:
Address (lfdIfferent from location)
City/Town
Ma
State
'TOWN OF NORTH ANDOVE,R
11E.A1,1T1-1 DU,PARTME. NIT
01845
Zip Code
State
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping
0//e?-1/
2. Quantity Pumped:
Date
3. Type of system: El Cesspool(s)
0 Other (describe):
4. Effluent Tee Filter present? El Yes
5. Condition of System:
6. System Pumped 131:
ame
eptic Tank 1111 Tight Tank
L,-
/000
Gallons
0 Grease Trap
If yes, was it cleaned? 0 Yes 0 No
Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
St ' Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Sigtur of Receiving Facility
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