HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 6/7/2018 (3) C0 , wr )n e a h of Massachusetts
of No. Andover, MA
I.W1 PLIMping Record 07
At jr,30,4"E'11
Fornrl
DEP r t.IJs` provided thi^ form for use by local Boards of Health. Other forms may be used, but the
illt01 Must be suostantially the same as that provided here. Before using this form, check with your
�af I--�o qh to d to. rn-ine the forr.n 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
accorn ance with 310 CMR 15.351.
-
Importeln,.:'tJ'Vhen
filling ouforms
on the(orrnputer,
use only the tab ��_ II�J L_��/U
key to rnov,-�your A An
cursor cdc not ,r,:, i r`(iC:a7V't r MA
use the rci'?nsre, _..._ _....__.. ..---..._.
key. C.',l �7 State Zip Code
2, Owner,
l tJ
- -
aru,
(i:�cfffe^nant frmn location)
c iod-f own State Zip Code
Telephone Number
c: c,.a =�urTtair�g date 2. Quantity Pumped: Gallons
Cesspool(s) ❑ Septic Tank ® Tight Tank ❑ Grease Trap
i t'a':` c.Yr (ciascnbe): — -
fl. k:i a r) ]"'ee Fier present? 0 Yes No If yes, was it cleaned? ❑ Yes No
c;ondc hien of component pumped;
(i. r 6-1 Arnped By:
Vehicle License Number
�'.wvSetarlc 58 So. Kimball St., Bradfor ... ._
where contents were disposed: 1
.� v1ill `':. i3raciford, MA
....
Gate t
I
.u f Rocs iOrfrri (or attach facility receipt) Date
t5form4.doc� 11/12 System Pumping Record•Page 1 of 1