HomeMy WebLinkAboutSeptic Pumping Slip - 235 OLD CART WAY 11/16/2015 . - -
^ ^
^
Commonwealth w,F'm a8 sac`Qsetts
City/Town of North Andover
JVer
-y- r-m Pumping Record
'
Form
`~
OEP has provided this form for use by local Boards of Health. Other forms may be.uaed, but the
information must be substantially the same aathat 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 |omo| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCK8R15.351.
A. Facility Information
|m`v� nt!VVhon
filling out forms 1. System Location:
on the computer,
use only the tab
key m move your Address
cursor-do not
h Andover
N
vsemee$um - ------------- ---'---- - ------------''--- ------------'----
keyCity/TowCity/Town State/uwn State ZipCnda
2.
Name ---- ------'-----------------------
-____-_-_-_ _-'_'___--'-__-___-___'__
A����uJ��t�mbc�o >
City/Town �����----------'----- '-- - �State----'--------- Zip Code |
��������
Te|epxonewumte,
B. Pumping Record �
1. Date of Pumping Quantity Pumped:
o�a - � GaUunu
3. Type ofsystem: Fl Cesspool(s) M SeptiuTanK El Tight Tank [I Grease Trap
[] Other(describe)- ----'---------------'---------'--'----' --
4. Effluent Tee Filter present? UYes F� No |f yes, was if cleaned? E] Yes E] No
5. Condition ofSystem:
`
-7-l-------'--'-------------
0. System�~ PumpedBy-
Name, _ve__Cle_o_enaeNu_m_e-r__-_
------__-Company
7. Location where contents were disposed:
Stevvart'a Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835______________
Signature ofHauler ���--------------- Date-----''-' - -----------------------
Signomnauf Receiving Facm� -'- -- -- '---- ' �Date- --- '----'-- -----------------
t5form4.doc-03/06 System Pumping Record-Page 1 of 1