HomeMy WebLinkAboutSeptic Pumping Slip - 14 CRICKET LANE 8/15/2017/ ~ �
` '
C.�y/ ov . of North Andover
*�~ P r�~
\\
YS
0Pumping Record
-0 IPI\
DEP has provided this form for use by local Boards of Health, Other forms may be used, but the
information must besubstantially the same eethat 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
4he local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCMR 15.351.
A. Facility Information
`
' /mpvnam:vYxmn .
filling omfonn§ 1. System Location:
on the computer,
use only the tab
key mmove your Address ��� ------- �
ourso,-dnnw -
use the return
key. "`r'"w'' State Zip Code
2.
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
' B. Pumping Record
-
1. Date of Pbmping2. Quantity Pumped:
Date
3. Component: ( ) [� Septic � El Tank � Tight � 7�p
' /
El Other(describe):
4. Effluent Tee Filter present? R Yes �� No If vmam �dmsn��? �l Yes �l No
-- 7- ' ��
5. Observed condition ofpumpe
d: �compone?n
8. S - `
Na 7e Vehicle License Number
ot
Stewarts Septic So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill stbnadford ma
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt)
'
mmnn4�oo n�2
-�~~ System Pumping Record`Page 1of1