HomeMy WebLinkAboutSeptic Pumping Slip - 65 STANTON WAY 5/5/2017 ~
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CCTOol8ea|fh of Massachusetts
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City/Town C�\�/� x�/ NO ANDOVER
System Pumping Record
Form 4
DEP has provided this form for use bylocal Boards ofHealth. Other forms may beused, but the
information must besubstantially the same asthat provided here. Before using this form, check with your
|ouo| Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of H | h or otheri h i within days from
accordance With 310 CIVIR 15.351.
A. Facility Information
Important:When
filling.~ out forms 1. System_ Location:
on the computer,
use only the tab
keywmove your Address
cursor-do not
No Andover
use the return
cuyxuwn state Zip Code
_',
2. System [> neVQ A -10 UAddress(if different from location) �
Name
citiruwn State Zip Code
'
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: || Cesspool(s) [�—SeptkcTank M Tight Tank El Grease Trap
El Other(describe):
,� N�
4. Effluent Tee Filter present? [] Yea �� o If yes, was it cleaned? Fl Yeo 0 No
5. Observed condition ofcomponent pumped:
8. System Pumped
4-1(
Name Vehicle License Number
8bawmrte Septic 58 So Kimball St Bradford k4
Company
7. Location vvheny contents were disposed:
20 so mill otbradfnrd noe
Signature of Hauler Date
Wuie of F ch facility receipt) Date
-Si7g n Cec-,�,7v—i,05ciiiiiy�(�o;ratta(
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