HomeMy WebLinkAboutSeptic Pumping Slip - 976 TURNPIKE STREET 8/15/2015 . ^ - .
^
Commonwealth o' f moa,�sacF
usetts
Ci6�y TLVR of North Andover
over
System ��u��K�^n� R�����d
` " ~~ TOV��OFU0n[Hk!\��VB<
Form 4
HEAL HDE5\�x�d\|
DEP has provided this funn for use by local Boards of Health. Other forms may be uued, but the
information must be substantially the same anthat 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 10
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCK4R 15.351. �
A. Facility Wormat'oi0 ---- |
Important:When
filling out fnnnn 1. System Location:
on the computer,
me��t�t� ~ �
�ymmmeyour xuunma - �-�����'----------------------------' - -'-'---
cumur-unmot
use the return North Andover
xey uv«/»w» mate Zip Code
2. System Owner:
mame
--------
Address(if uiffenan,frnm|vc�tion)_-------- --' ------ --------------------'-----------
CityfTmwn ��--------- '------' -' - ���ate------------ Zi,...Code
---------- �
Telephone Number �
B. Pumping "^~~~~~,"~"
- '
1. Date of Pumping -----------'-'--- 2 Quantity Pumped: ---
Date � � � Ga|mno
3. �� ���m� � Ka\ � Septic Tank � Tight � Grease Trap
'. �~ Cesspool(s) �� �� ��
L1 Other(describe): -------'-------------'--'----------........
-----
4. Effluent Tee Filter present? Fl Yes No If yes, was it-olbaned? F-1 Yes R No
5. Condition of System:
(1') .......-----------______ .......__
8. System Pumped --
Name Vehicle License Number ---
Stewart' Septic Service l �
Company ��-------' --- -- '
�
7. Location where contents were disposed:
Stewart' P 01835
Signature ofHauler ���-'----------- ���e---''-' - ----- --
SignamreufReoemnnraom----' -- - - ''-'-- ' Date-----'---
om�4.doc-03/06
System pumping nnoom`page 1 m1