HomeMy WebLinkAboutSeptic Pumping Slip - 1504 SALEM STREET 6/1/2016 Commonwealth of Massachusetts
_ CityfTown of
System Pumping ecor Tai ANDOVER
Form
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 Pumping Record must be submitted to
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:
e l ocatlon
When fillip out I System i
form on the
9 � 4 X
computer,use
only the tab key State _ Zi Code
to move your
cursor.do not City/Town P
use the return
key.
2. Syste O wn 7x'�VQ Name I")a ..
Address(if different from location)
Cityrrown State Zi bode
Telephone Number
B. Pumping Record
Date
1, Date of Pumping — —. _.—__—_ 2. Quantity Pumped:
Gallons
I Type of system: ❑ Cesspool(s) U, eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present. ❑ Yes �,N,6 a
7 � If es, was it cleaned. Yes
5. Condition of System: r
6. System Pumped By:
Name ',t Vehicle License se Number
',. (,
_ -_._....._._..— ... — —_. _.. ._._.....
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receivng Facility Date
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