HomeMy WebLinkAboutSeptic Pumping Slip - 45 SUGARCANE LANE 6/7/2018 _
City/1-own of No. Andover MA
a
- Fort�ril
, Wa�
EP It° � provided this form for use by local Boards of Health. Other forms
I g ibe used, but the t
informatiO,I must be suostantially the same as that provided here. Before using this form, check with your
local !_�);rv' 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 j
accordance with 310 ( MR 15.351.
hiforrination
Important:When
filling out forms 1. ()yS�tEffl-i Location:
on the computer,
use only the tab
key to move your Ad( res;
cursor-donot i c1edo AndoverMA
use the return —_._ _.. .......... . .._.,,,.. _ --- --..
key.
CityFro"vn State Zip Code
^AB 2. Systerrn Owner:
lab i4
Narne.
lPfttlll ��
/-Address(if different from Location)
City/Town State Zip Code
_. ......_
......._..............
Telephone Number
B. Mrd
�' •� " / ` c
1. D&te of Pumping — - 2. Quantity Pumped:
Date Gallons
3. Component: Cesspool(s) /Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): __.....__ _........... .............. ............--
4. Effluent Tee Filter present? ❑ Yes ❑'No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition o component pumped:
6. SysteM Pumped By: /
Name Vehicle License Number
f;,'cewarKs Septic_58 So. Kimball St., Bradford,MA
Company __...
%. Location where contents were disposed:
.20 So. Mill St., Bradford, MA
tii —j
01nat/,/�T�f Mauler Date
_._—..._ _ ._._.........._.. _...._ ..
S3 gnatnre of Receiving Facility(or attach facility receipt) Date
I
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