HomeMy WebLinkAboutSeptic Pumping Slip - 93A TURNPIKE STREET 10/16/2017 RECEIVED
Commonwealth of Massachusetts
TOWN OF NORTH ANDOVER
City/Town of HEALTH DEPARTMENT
System Pumping Record NORTH ANDOVER
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 must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351,
A. Facility Information
Important;
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your Z�'
._____„/—� - .
cursor-do not
use the return Cityrrown 96afe Zip Cade
- -
key. 2. System Owner:
Address(iffroiWi;ca`tio'-n—) .......
City/1 own StateAD ._-Zip Code
PI-7
fel phone Number
B. Pumping Record
1. Date of Pumping26 OL
-6—at.e-q 2. Quantity Pumped: Ga.lions )
3. Type of system: El Cesspool(s) ❑ Septic Tank ❑ Tight Tank Cb—Grease Trap
El Other(describe):
4. Effluent Tee Filter present? F-1 Yes EK No If yes, was it cleaned? ❑ Yes f_-1 No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Company
STEWARTS SEPTIC SERVICE
7. Location where contents were disposed:
58 SOUTH KIMBALL ST.
BRAD FORD,MA-01 835--...-
978-372-7471
TI 9"nii u�' —o -Hauler---- Date
Signature of Recji vi ng Facility Date
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