HomeMy WebLinkAboutSeptic Pumping Slip - 119 DUNCAN DRIVE 11/16/2015 - ~ ^
�
^
�
Commonwealth «f88a,,§ chusetts
City/Town of North Andover
over
System Pu00�^�� Record '
` . ~~
Form 4
OEP has provided this form for use by local Boards of Health. Other forms may be ueed, butMhe
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 local Board of Health nr other approving authority within 14 days from the pumping date in |
accordance with 310 CyNR 15.351.
� .
A~ Facility Information
Important:When mu,
filling out forms 1 System Location:
on the computer,
use only the tab
key m move your Address ���----------------'-----'--- -----
cursor-uvmx
North Andover
use�e�m� ___-_ ---�' --.- _ '_'--- ---'-- --------------
key. ^'yv'"=" State Zip Code
0 &
2. System Owner �
Name - � - ---- -' -'---'--------------'--
-------
Address(if different from lo'ation)---------- --'-----'------------------ - |
Cky[Tvwn --------------'-�'-- - �tate__'-------- ........- ---------------- �
��Coue |
'
-- --__
.~�r-=..~.~=
B. Pumping Record �
1. Date ofPumping Date --- 2. Quantity Pumped: --Ga
3. Type of system: Fl Cesspool(s) Septic Tank El Tight Tank Fl Grease Trap
El Other(describe): ......
----- _-
4. Effluent Tee Filter present? Ej Yes E] No If yes, was it cleaned? F-1 Yes F-1 No
5. Condition ofSystem:
�����������
. _'-_..
Vehicle License Number
Ste wart's Septic Service
Company �-----' -- '-
/. Location where contents were diypoaed�
Stewart's Pre-treatment Plant, 20 So Mill_Bradford, Na 01835
Signature vf Hauler ���----------- --'------''-'' ' ---- ----
� Date
Gignotum of�ecei'vingFac|� - --- -'' —�--- ���te---- ---'- ---
mmnnv.doo onms �System Pumping Record-Page 1 of 1