HomeMy WebLinkAboutSeptic Pumping Slip - 2198 TURNPIKE STREET 8/13/2015 ^ ^ ^ ^
Commonwealth ' 'R�
`��0O[����V���vu / �� ,v'a8saChUsetts
City/Town of North Andover
���
��s*e�� ��u����~n� �������d �u
-r00 �� Pumping TO�N�FNO»]H�M��»ER
DEP has provided this form for use by local Boards of Health. Other forms may be used, butthe
information must be substantially the same as that provided hero. 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 ur other approving authority within 14 days from the pumping date in
accordance with 31UCyWR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location.-
un the computer, ��/ c\�7
use only tab
key m move your Aduvaeo ���«-- — --------'-------- ----'— --
cursor'dmnot
use the return N-- '---
key. uty'/vw»
State Zip Code
2. System Owner:
wame ~~ ` ` -�-~-----'--------'---------------------------------------------
��------
Address(if different frnm|�cann'-------- --' —'--- ----'----------------------------
City/Town —�----- '---'--' -' �- 7State''------------ ZipCode
------------
Te��hunemum��
B. Pumping R~~~~^"~°
1. Date of Pumping P/ng ------------'--- 2. Quantity Pumped: --- �Date
Gallons
3. Type ofsystem: Cesspool(s) Septic Tank Tight Tank Grease Trap
`
[l Other(describe): -----'—'------........ ---''--'---------'......
---- --
4. Effluent Tee Filter Present? El Yes El No |fyes. was ito[eaned? F� Yes F1 No
5. Condition ofSystem:
�������
0. System Pumped By:
____�-
Name Vehicle License Number
Stewart's Septic Service
Company �------- --' '—
7. Location where contents were disposed: �
Stevvar[n Pre-treatment Plant, 20 So. Mill Bradford, Ma01835 _____________
Signature ofHauler --------'--' ---'--
Signature vf Receiving Facility --- --- ----' ' Date----'----'-- —'--
mm�4.doc-03/06
System Pumping Record'page 1 of