HomeMy WebLinkAboutSeptic Pumping Slip - 196 CARLTON LANE 12/8/2016 ~
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Commonwealth �
��(]�]�l���l\8/����/u ^ ��/ Massachusetts
City/Town of No Andover System Pumping Record
Form 4
DEP has provided this form for use bylocal Boards uf Health. Other forms may bmused, 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 une. 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 310CK4R15.3B1.
A. Facility Information
Important:When -
filling out forms 1. System Location: MuH|H8MOOVER
un the computer, T�VU��r DEpARTWENT
use only the tab / HEALTH
key tn move your Auumnn
cursor'donot
use the return --------
hey. Q\wTmwn State Zip Code
2. System Owner:, �
Name
Addr ess(if different from location)
�
Qty/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Z
- // 2. Quantity Pumped:
2 Gallons
3. Component: |} Cesspool(s) UoTank F-1 Tight Tank Fl Grease Trap
E] Other(describe):
4. Effluent Tee Filter present? R Yes [A-ITo If yes, was it cleaned? El Yes El No
5. Observed condition of component pumped:
0. System Pu d B_ '5-
Name Vehicle License Number
Stewarts Septijq 58S Kimball St B dfond K4
Company
7. Location where contents were disposed:
20 so mill st br -m
Of ra�uil;e-r-
Signature of Receiving Facility(or attach facility receipt) Date
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