HomeMy WebLinkAboutSeptic Pumping Slip - 53 BRIDGES LANE 1/6/2016 L�IEA l
Commonwealth of Massachusetts �
City/Town of North Andover �� 013
s System Pumping Record TOWN
1, NCR°tHANDOVER
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DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location: - C
on the computer,
use only the tab
key to move your Address t
cursor-do not North Andover Ma 01845
use the return .... _.._. _..
key. City/Town State Zip Code
,�
2. System Owner:
CA
11
Name
elwn
Address(if different from location)
City/Town State Zip Code
-- .. -----
Telephone Number
B. Pumping Record
2. Quantity Pumped: -
1. Date of Pumprng1 Y Gallons
Date
3. Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): _-......._. / ...... ...._.
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: /
6 S stem Pumped By:
_. -�
_ r �
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
'� iLwart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
uler Date
11�j A,
Signature of Receiving Facility Date
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Cor anon vealth of Niassachuselts
Massaciuts
ells
system Pumping Record
System Owner System Location
(Ac� V-\
Pum t yin Quai►tity Pumped: l gallons
Date of g:
Cesspool:
No Yes Septic Tank: No Yes
System Pumped by: 9cire4Olf 0&i#1tided License #
Contents transferrred to : Greater Lawrence Sanitary Qistrict
Uate: inspector: