Loading...
HomeMy WebLinkAboutSeptic Pumping Slip - 128 BRIDGES LANE 10/26/2016 Commonwealth of Massachusetts RECEIVED r City/Town of No Andover NOV 14 System Pumping Record Form 4 TOWN 01- NUR I H/�t�&B"t,.1'VER .... HEALTH OEPA IMENT 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:When filling out forms 1, System Location: on the computer, , / use only the tab C key to move your A dr s cursor-do not `� ...._. use the return -- key. City/Town State Zip Code 2. System Owner: r ��1...1_..__L .._. . ...._. .....__._ .........._ ......_ ............................... _ __.._- Name — ___.-.__ _._._ mtLm _ Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1 - / 2. Quantity Pumped: . Date of Pumping Date Gallons 3. Component: © Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): -- _ ___ ------- 4. Effluent Tee Filter present? ❑ Yes O'No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped- 6. System Pumped �_ --- - — --- ----- _._.. . Name Vehicle License Number Stewarts Septic 58 S Kimball St Bradford Ma Company 7. Location where contents were disposed: 20 so mill st bradford maw Signature of auler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11112 System Pumping Record•Page 1 of 1