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HomeMy WebLinkAboutSeptic Pumping Slip - 73 RIVERVIEW STREET 12/8/2016 � Commonwealth n� K�Massachusetts �^������[J[l\&����/u ' c/n /v/��������(�, /U��^��^z ��'+�//7-r` /,f City/Town `�/ No Andover System Pumping �� � ����u��� n���K��v� _ 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 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 31UCK4Fl15.351. A. Facility Information Important:When filling out h,nno 1. System U -- un the computer, use only the tab key k,move your *du cursor'uonot use the return key. _`,'..... State_ Zip Code 2. System Owner: VQ me Address(if different from location) Qhlrfmwn State Zip Code B. Pumping Record 1. Date of Pumpin8 tib/ Pumped: Date s 3. Component: [l Cesspool(s) nk El Tight Tank Fl Grease Trap �1 Other(describe): 4. Effluent Tee Filter present? E] Yes 6' No If yes, was it cleaned? U Yes U No 5. Observed condition ofcom nent pumped: (9;-0 -. -'_ Name Vehicle License Number Stewarts Septic_58_So Kimball St Bradford Ma Company 7. Location where contents were disposed: 20 so mill st br dford ma le ignature of Haule Date S ign eceiving Facility(or attach facility receipt) Date ignature of Page 1 of 1 t5forrn4.doc-11/12 System Pumping Record