HomeMy WebLinkAboutSeptic Pumping Slip - 145 BRADFORD STREET 4/7/2008 FROM PHIAL hU7, Apr 28 2008 02:06PM P1
Commonwealth of Massachusetts
rb it /Town of NO. ANDOVER
t System Pumping c r
Fart" 4
- DW has provided this frrflrl for 11SP ley local t;oarels of ftealth. Other forms may be used, but the
infor t-nation rnmA be ubsWntialiy the saille as that provided here. Before using this form, check with your
local Board of Health to detol-mine the fOm)they use. The System Pumping Record must be submitted to
the local Board of Health or other approving Authority-
. Facility Information — ---.-- —
Important:
LNhe11 fllling out 1- System Location:
forms to the 145 BRADFORD ST.
cornpuier,use
only the tab key Address
toirloveyour NCB.ANDOVER MA 01845
C011,01-do not
use the return
City/Town State Zip code
isey. 7_ System owner,
1�. MARJORIE QAUDETTE
ivame
irsm ' Address(if different from location)
City,Town State Zip Code
Telephone Number
13. Pumping Record
1- Bate of Pumping 4 /08--- — K.. Quantity Pumped:
f)afr� Galas
f
:3. Type of system: ❑ (fesapool(s) SeptlG Tank ❑ Tight Tank
other(describe)_ __.-----._.. ----- -- --._..
4. Effluent Tee Filter present? ❑ Yes U,� /No It yes,was it cleaned? ❑ Yes ❑ No
5_ Condition of System.-
0, system Pumped By'
Berijairtin :chute H79't��
Name Vehiole License Number
J's Septic& gain
rornpany
7- Location where contents were disposed:
G wU l —
eti .cf Hauler Date__
U
t5form,i dbc-06103 system Pumping Record-Page 1 of 1