HomeMy WebLinkAboutSeptic Pumping Slip - 691 FOREST STREET 12/8/2016 � ^
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City/Town of
No Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health, Other forms may be used, but the
information must be substantially the some 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 1n
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31UCK8R15.351.
A. Facility Information RECEIVED
Important:When 1. System Location: 2 0 16
f illing out forms on the computer,
use only the tab
key hn move your Address HEALB iD2RAR�WENT
cursor'uonot
use the return -------- -----------------
key. CityfTvwn State Zip Code
2. System Owner:
Name
Address(if different from location)
own State Zip Code
B. Pumping Record
1. Date of Pumping ---����--- 2� Quantity Pumped: Gallons
Date 1 Component Ceaopoo|/a\ [J/SepdoTank El Tight Tank Fl Grease Trap
[l Other(describe):
4� Effluent Tee Filter present? [I Yes El No If yes, was it cleaned? El Yes F] No
5. Observed c ndition of component pumped:
6. System Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball 5t Bradford K8
Company
7. Location wh�
",eretontents were disposed:
mill st bradford ma..
_
� Sign, Date
-Signature of Receiving Facility(or attach facility receipt) Date
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