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HomeMy WebLinkAboutSeptic Pumping Slip - 201 CARLTON LANE 11/16/2015 � ' � Commonwealth of Ma_,;sarhuseyt ` [`' ofk�� rf� Andover City/Town{J\8/[l ��^ , v�]. `, / / �yl`^over System Pumping Record ' DEPaPo i e h s f m o e b lo | Bo d o Ha . O e fmama bu� b e infonnaMnn muatbosubotantaUytheaemeesthatprovk]ed here' Before using thiafo--. oheckwth your |oma| BoondofHea|dltodetenninethaformtheyuae. The3yntemPumpinQReoordm .` beaubmitedto tke |ooa| BoardofHea|thorotherepprovinAeuthohtyvvithin14deyahnmthmpumpin0'd�tein 0000rdoncowith31OCK8R15.351. - A. Facility Information Important:When filling out forms 1 System Location: on the computer, / /- use only the tab key tv move your Address cursor'unnot North uae�emmm --� - --'--- ------ key. ~'y''"~" State u~�~~~--- Zip Code 2. System Owner: A 9D1� � - Name / �-�' ----'-----'--------- Address(if-different fromIoa�n) __ ------- -''-- ---' C�y�own �-------------' - - ----'------�----- State Zip Code /olepnonemumoe, B. PUMPing Record - 1. Date of Pumping - 2� Quantity _5 on s 3. Type ofsystem: El (a) Septic Tank Fl Tight Tank El Grease Trap El Other(describe)- 4. Effluent Tee Filter present? 0 Yes Ej No If yes, was hcl'ean--d? [_l Yes No 5. Condition of System: _ .............- ......------- O. System Pumped By: � mame � - -- ~___- Vehicle License Number------ Stewart' Septic Service Company ----- '-- -- 7. Location where contents were disposed: °u`wmtu Pre-treatment Plant, Bradford, Ma Tignamreor:au�r ��----�----'-----' --------'--- ---' 8i gnamreof ece_iv ng paoi I,ty -'-- -' -�-' -'----' ----'- --------------- t5fmmmm03106 System Pumping Record-Page I of 1