HomeMy WebLinkAboutSeptic Pumping Slip - 246 BRADFORD STREET 10/19/2015 ^ � ^
CoD]monwealthnf'Ma � sachUsmtts
City/Town of North Andover
[yver
System Pumping Record '
Form 4
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DEP has provided this form for use by local Boards ofHealth. Other forms may be ua*d, but the
information must be substantially the same ao 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 bo submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCMR15.351.
A. Facility Information
important:When �
filling out forms 1. Gyehym Location:
on the computer,
use only the tab _� ^]/ ______________________ _ __________________
��mmnveyovr Address _
cursor do not
North-'h
' ''-`'~' -------------- -.....
'--'- '
key. un«/vwn ume Zip Code
2. System Owner: � &
L4 /�
Name
-------
Address(if different from`location)
------- -'''----- --------'------------'------------
Citynuwn ������------'----- '-- - 7State-------'----- Zip Code
Telemmmwvmbor /
B. Pumping Rec"ord
/��l
/0
' ���
1� DateofPumping ----�-/ - 2� Ouan�yPumped� ---
Date � Gallons
1 Type ofsystem: F1 Cesspool(s) Septic Tank El Tight Tank El Grease Trap
LJ Other(describe): ----------------- ------ ------------_—__'
4. Effluent Tee Filter present? Fj Yes [:1 No |f yes, was ifcleaned? F] Yes M No
5, Condition ofSystem:
0. System Pu ped8y
Name / ' / / ��------- --'------'------------
Vehicle License Number
Stewart's_.Septic Service
Company ��---'--- --- '— - �
7. Location where contents were disposed:
Shyworys Pre-treatment Plant, 20 So. Mill Bradford, MaO1835 _____________________________
Signature nfHauler �------------------ Date------'''-'' ----'- --
��i 9na�mofneonmnupac| y---'-- ��te--------''-- ---
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