HomeMy WebLinkAboutSeptic Pumping Slip - 124 PENNI LANE 5/30/2017 Commonwealth n� Massachusetts
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City/Town of f Andover
��*vu�* Pumping
Record
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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 ommm as that provided here. Before using this form, check with your
/Vna| Board of Health to determine the form they use. The System Pumping Record must be submitted to
he localB Health or other approving authorityi from the p ina date in
accordance with 310 CIVIR 15.351.
A. Facility Information
Important:When
filling t forms 1. System Location:
on the cornputer,
use only the tab
key wmove your awre*
cursor-do not
NodhAndover
use the r�urn
key. ChwTowm State Zip Code
2. SyohemO
1 J XY)
Name
--------------- ------------------------- -----------
Address(if different from location)
City/Town State Zip Code
ro|ephonmNumbmr
B. Pumping Record
1 Date of Pumping '-- 2 Quantity Pumped:
1. Date Date � � Gallons
3. Component: Fl Couspoo|(s) V/SepticTonk F-1 Tight Tank [l Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Fl Yea M No If yes, was it cleaned? El Yes Fl No
5. Observed condition ofcomponent pumped:
--------------------
6. System Pumped By:
w�np
Vehicle License Number
Stew�rteSe ti 58S U Ki b StBradford KX
Company
7. Location where contents were disposed:
; i|| b dfnrd ma
ur,
natf Hauler Date
Signature mReceiving Facility(or attach facility receipt) oam
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