HomeMy WebLinkAboutSeptic Pumping Slip - 1077 OSGOOD STREET 5/12/2016 Commonwealth o-IF
Cityff own of Nbr-Lh Andover v
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-SYstem Pumps ng Record
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DEP has provided this form for use by local Boards of Heal'�h, Other forms may be used, but to
information must be substantially the same as that provided here, Before using this form, checl
local Board of Health to determine the form they use. The System Pumping Record must be sL
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facifty Wormation
Important:When
filling out Torms 1 System Location:
on the computer,
use only the tab
key'to move your Address -------
cursor-do not
N
use the return orth Andover
key. C'ty/Town
State,, Zip Code
2 System Owner:
❑� e
Name
Address Ci f deferent fro W location)
-ETtyl-,�.-n —-
Zic Code
Telephone Number
PUMPing Record
I Date of Pumping
-D"ateZ 2. Quantity Pumped-,
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ ight Tank ❑,Grease
❑ Other(describe)-
4. Effluent Tee Filter present? ❑ yes ❑ No 11 yes, was it cleaned. ❑ Yes N(
5. Condition of System:
----------
6, System Pumped By:
_
-V-,e,hicle_L_icen_s,e* Number
e
S'L wart's Septic Service
Company --------------L�_____ - - -
7 Location where contents were disposed:
..St warts Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
Signature of Hauler
• Date
Signature Tof Receiving Facility -
Date
Z5',o--m4.doc-03/06
System Pumping Record-PS