HomeMy WebLinkAboutSeptic Pumping Slip - 26 TURTLE LANE 5/7/2018 Commonwealth of Massachusetts
Or
City/Town of No. Andover MA,
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System Im4 Pumping Record
For
DEP has provided this form for use by local Boards of Health. Other form n i66 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 310 CMR 15,351.
_.. ....... �_........_.—._.._._
A. Facility Information
Important:When
filling out forms 1. System Location-
on the computer,
use only the tab
key to move your Address
cursor-do not �mw,,
use the return � `: „._ ------- MA,m. ....__... .. _._...... ._
key. CityfTown State Zip Code
2. System Owner,
Dame
re2an
— _....__. ..........................------------
Address(if different from location)
CityfTown State Zip Code
Telephone Number
B. Pumping Record — _.._
1. Date of Pumping D t _. .._m _......__... . .... 2. Quantity Pumped: Gallons
) - --
3. Component: ❑ Cesspool(s) M--Se Tank. ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? F-1 Yes rNlf es, was it cleaned?
, !� Y El Yes ❑. �.,A
5. Observed condition of component pumped:
6. System Pumped
vi
. '" _
Name T-,L Vehicle icensein,, er
Stewart's Septic 58 So, Kimball St., Bradford MA
Company
7. Location where contents were disposed:
20 So,,,Uhll St., Bradford, MA
(
d' ature of Hauler Date
-
Signature
t
Signature of Receiving Facility(or attach facility receipt) Date
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