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HomeMy WebLinkAboutSeptic Pumping Slip - 250 ABBOTT STREET 12/12/2017 Commoi wealth ofMassachusetts v CitylTown of Borth Andover System Pumping Record Form 4 b� I �:iwcii ()VER' i 4�i DEP has provided this form for use by local Boards of Health. Qthe� orms may be used, but the information must be substantially the same as that provided here,"Before using this form,check With local Board of Health to determine the form they use.The System Pumping Record must be submitte the local Board of Health or other approving authority Within 14 days from the pumping date in accordanoe with 310 CMR 15.351. } . I A. Facility Information Importarr When flc ling out forces 1. System Location: on the computer, , R; use only the tab key to move your Address cursor-, do not use the return CWTown owm State Zip Code key. Qk 2' S'lystem Q er: � U r7�Gg r fA At Name` Address(if different from location) City/Town State o ' _ (f'6 ` Telephone Number B. Pumping Record 1. . Date of Pumping 1.1' . Quanti Pumped: p g DateGallons 3. Corrlp6��p`ic onent� ❑ cesspool(s) Tank ❑ Tight Tank © Grease Trai ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Y90KNo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed conition of " mponent pumped: 6. stem Pum y: , Nene Vehicle License Number Stewarts Septic 58 So Kimball St Bradford Ma Company 7. Location where contents were disposed: 20 o mill sf bradfo ma Sign re of Naut �•F Date Sj nature of Receiving Facility(or attach facility receipt) Date tr,,FnrrnA rl n.1111'7 0-