HomeMy WebLinkAboutSeptic Pumping Slip - 1627 OSGOOD STREET 8/28/2015 ^ . -
Commonwealth � '�� r� � �����
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City/Town of North Andover
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System ���0N�~�� ������� '
_ � Pumping�� ^ ^=� " = ��NCFN�rJHAN0JV[R
Form 'A
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 here. Before using this form, check with your
local Board of Health tu determine the form they use. The System Pumping Record must bmsubmitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCMR15.351.
A. Facility 0U0for00at^ol0
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key m move your auureon ����-------------------------' -----
cursor'dnnot
use the return North Andover
-----------'- ---'--'�- '
key. City/Town State Zip Code
2. System Owner: 4 & &
Name �����---~=----'---'--' ' '--'' '---------'--------'----------'------'
-------'
Address(if different from looation---- ---- --' '---- -------'-------------------------
City/Town -------'-----�'-- '- �State-------------- Zip Code
----------- |
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Te|epxonewu�ber
B. Pumping Record"
1. Date of Pumping -----------'-'--- 2 Quantity Pumped: ----------------
Date � � Gallons
3. Type nfsystem: Fl Cesspool(s) [I Septic Tank F� Tight Tank El Grease Trap
`
ElOther : -------'-------------'------------''-'----- --
4. Effluent Tee Filter present? Fl Yes R No If yes, was if cleaned? M Yes F� No
5, Condition ofSystem:
0. System Pumped By: �
______
',""'= Vehicle License Number
Stewart's Septic
Company ��--------- --' '-
7. Location where contents were disposed:
Stewart'a Pre-treatment Plant, 20 So Mill Bradford, Ma 01835
Signature ufHauler ���e----''-'' -'---------------------
Signatonaofreueivinopoomty-- -- - - ' --- ' �Date----- ---- - - '-'-------------'-
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� System Pumping Record'pase 1 w1