HomeMy WebLinkAboutSeptic Pumping Slip - 266 LACY STREET 1/11/2016 commonwealth of Massachusetts
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City/-Town Of Nbr4th Andover
ystem Pumping Record
Form`4
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
local Board of Health to determine the form they use. The System Pumping Record must be submii�e
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 Syste m Location:
on the computer, JAN,useoy
key to move your Address
cursor-do not
use the return North Andover
-- —..._._.•., .
C !Town — -.._.._. ---
key. State Zip Code
2. System Owner:
Na- me ----------------- - - - -- - - ---.------
_ ......_............ ..._
Address(if different from location).._.
City/i own
State Zip Code
Telepfione Number B. Pumping Record
1. Date of Pumping pate �f�-�--'•' 2. Quantity Pumped: Gallons ---
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: r
6. System Pumped By:
_— _. _ _
Name _.—._...._ .. _ ..—._.. -- ---°---
Vehicle License Number
Stewart's Septic Service
Company --._..... ......_ . ...__..
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So_Mill Bradford, Ma 01835
Signature of Hauler . —.---- .__... ------°-
' Date .. . ...._.._...--•--------
Signature of Receiving Facility
Date ._...._.._.
t5farm4.doc•03/06
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