HomeMy WebLinkAboutSeptic Pumping Slip - 554 FOSTER STREET 8/3/2015 - -
. �
^
COmmonwealthnf'Ma � sachusetts
��' �� ��� rf� Andover
City/Town[�\8/�� `�/ ,nC). �o / ^v�l`�over
System Pumping Record '
Form 4
UEP has provided this form for use by local Boards of Health, Other forms may be uaed, 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 |000| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CyWR 15.351.
A. Facility Information - ~~~C~�m � m~u�
Important:When |
filling out forms 1. System Location:
on the computer,
use only the tab
keymmoveynur -
cumor-dond -- MEALlHDEKRT�.)�y�
use the return North Andover -__-_ _------- -----------'---
xay. ^"p'mw/ state Zip Code
2. System Owner: � &
Name / �-- -----------------------
Add m�(if� rent from��ow)--------------
City/Town �-------- -- '- �S�� -------'-----' Zip Coue �
Te-- __.be
B. Pumping Record
'
1. Date ofPumping ---��--�---���-- 2. Quantity Pumped: Gallons 3. Type ofsystem: [l kd Septic Tank El Tight Tank El Grease Trap
L] Other(describe): -----'--------'------_'_-__-
4. Effluent Tee Filter present? [l Yes E] No |f yes, was itcleaned? R Yes F-1 No
5. Condition ofSystem:
5. System Pumped 8
wam= - ��----- --'---------------- �
Vehicle License Number
Stewart' Septic ery
Company ��---'— -'--' '-
7 Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature ofHauler �-'-------'----- Da--�------'''-'' - -----
Signamnen[seoe�insp��| , -'- -- - ---' ' '6ate- -------- - ' ----------------
mmnn*.uuo^oams
System Pumping Record-Pag*1 of