HomeMy WebLinkAboutSeptic Pumping Slip - 250 ABBOTT STREET 12/8/2016 - -
Commonwealth � o+�.
��{]Dl�](�D\8/����/v ' `�/ /"/��������. /Q��.^�uu
City/Town of
No Andover
System Pumping Record
Form 4
OEP has provided this form for use by local Boards of Health. Other forms may be nned, 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 nr other approving authority within 14 days from the pumping date in
accordance with 310 CK8R 153�1
� . RE
A Facility UK8f«»r00at^on L)F"C' M �3 7Q��
Important:When
filling out forms 1. System Location: I'M
on the computer,
use only the tab
key m move your xuunou
cursor'uonot
use the return ----
� --------- Zip Code
key. —`r'~`~^ ��
2. System Owner:
Name
Address(if different from location)
City/Town Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gillons
3. Component: kA El Septic Tank El Tight Tank [j Grease Trap
^
[]
Other(describe):
4. Effluent Tee Filter El Yes No K yes, was kcleaned? R Yes [| No
— Obse"d co di ion of component p mped:
zv
6. System P
'
/
Name ~------- Vehicle License Number
Stewarts Septic 58 So Kimball DtBradford KX
Company
7. Location where contents were disposed:
2Usomill stbradfnrd ma
Signature mHauler
Signature_ of Receiving Facility^ attach—' facility receipt), Date_
t5form4.doc-11/12 System Pumping Record-Page 1 of 1
/ `