HomeMy WebLinkAboutSoil Testing Results - 107 GRANVILLE LANE 6/10/2016 Cornmonwealth of Massachusetts
City/Town of No andovev,
Systern Pumping Record
Fore
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 Purriping Record.must be submitted to
the local Board of Health or other approving authority within 14 days frorn the purnping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return
key. .,ityfrown Mate "Lip Codo
. System Owner:
16611�j_ Anc
_— Name
Il-111
Address(if different frGrn location)
CityfTowll ;mate -- --
Zip Cade
'telephone Number —
B. Pumping Record
1. bate of Pumping .?. Quantity Pumped: 4 .
Gallons
3. Type of system: ❑ Cesspool(s) IZSeptic Tank C..j Tight Tank Grease Trap
[1 Other(describe:):
4. Effluent Tee Filter present"? Ye o If,yes, was it cleaned? Yes ❑ No
5. Condition of Systern: �
5. System Pumped Sy:
ante Vehicle License Number
Stewart's Seatic Service
Company —-
7. Location where contents were disposed:
Stewrt's Pre-troatmert Plant, 0 So. Mill Bradford, Pia 01835
Signafixx .o to°tr ei Date
Signature of Receiving Facility Bate
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CISP,has provided thW form for use by local Boards of Health. The System Pumping Record must
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w Facili i �°tT tati®n
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Telephone Number r,
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1 Data'of Pumping ' Dale 2, Quantity Pumped;
Gallons
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n r�ry Effluent Tea Flitar present?..❑ Yes o if yes, was It cleaned? El Yes ❑ No
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System Pumping Record•Page 1 or i
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SYSTEM PUMPING RECORD
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