HomeMy WebLinkAboutSeptic Pumping Slip - 1850 SALEM STREET 1/11/2016 ^ '
� Commonwealth of Ma,-� achusetts
City/Town mfNorth Andover
System Pumping Record '
Form 4
DBP has provided this form for use by local Boards ofHea|dh Other forms may beuaed b. the
information must beauba�/nt�Uy the same esthat provided 'ere Before using this form, '°u«'w�h yo
local Board of Health to determine the form they use. The S --n PumpinQRecord m'''^ ^""°` mi�ed
the �ca| BoandofHea�hcvo�erapprovingauth0�v��hin'--�' ' fn�mthepumpin"^�"��/�""
accordance w�h31OCPNR15.351. ' ' = --~ ''
A. Facility` -_-'-'_^.`~..
|mponant:*VVnon ]kW 1 1 901S
nWngmut forms 1. Location:
unUeuompu�� ' --� �
use only the tab MD�yJ��EN\
key m move your Address
mrsor-uo^m
North use the��m
key. City/Town ----- ---'-- � - '--------'-- --------__-
� State Zip Code ---
2. System Owner:
_
wame ----' - ---- -- '-------'--'------'------______--_'
Address(if different mom �n'----'--- -- -- --- ----'--------------'
~ obynown �--'---------- - ---'------------- -
S�� � |
\° _ _
Telephone Number ��-----
B. Pumping Record
/�
1 Date ofPumping --
k5()
7De�----^--f --- 2. Quanty Pumped: '��-allons
_
l Type ofsystem: F] Cesspool(s) Septic Tank El Tight Tank Grease Trap
LJ Other(describe): ------------_-,-�______--------_-'____ '
4. Effluent Tee Filter present? YesElNo |f yes, was kcleaned? El Yes No
5. Condition ofSystem:
----- ---~----- -----------------
- System 'Pumped By: |
Stewart's Septic Service Vehicle License Number
�
company ---'--'' '-- '—
/. Location where contents were disposed:
~~.,..`^ Pre-treatment Plant, 20 So. Mill Bradford, MaO1835_____________
^tgnatum,**auler --�----------' --------'--' -----
ugnamremReceimngpac|*v- ---- - - -'---- --'- - ---
t5fmrm4.dm03/06
System Pumping Record'Page 1 of