HomeMy WebLinkAboutSeptic Pumping Slip - 68 TUCKER FARM ROAD 6/7/2018 a� Cerl.rnon e lth of Massachusetts
�..-
City/Town of No. Andover, MA
PUMping Recorda] , J0 70
or `.
.> 11,4, rai r,)t.'VE
DEP h:;r provided thi:,form for use by local Boards of Health. Other fo' [A;%' ' IAkIbut the
infor i latioi must be Substantially the same as that provided here. Before using this form, check with your
loc'.i "".a.r.: of to d�trrrrtiine the form they use. The System Pumping Record must be submitted to
the loc,ai f;r,:aard of Health or other approving authority within 14 days from the pumping date in
accoro€,uric~e with 310 CMR 15.351.
- F� (Qi torfi"n tlon
Importaauai:I141hen
filling crit.�r,,rms
on the computer,
use only the tab � U G�CalC ir^ c c�
key to move your I
cursor-do not
"',"dioverMA
use thereturn ........... ---- -
key. n State Zip Code
�- r
Owner-.
rab i
grYn
l`dd ,,r= (F different from location)
0i:cYlTow n State Zip Code
Telephone Number
B. Cir
1. t. z". , o� Purnping �..._.._._. -------._ 2. Quantity Pumped:
Date Gallons
3. annr),neant: Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
__] C'.:Aier(describe}: _........_
..
4. i.l riw-:rnt Tee f=ilter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
5. Systeri i Pt,
Name Vehicle License Number
Sfew ai s Septic 58 So Kimball St., Bradford,MA
Company
any
7. Location ion where contents were disposed:
?0 f,o Mill St., Bradford, MA
S,gnaadaro,of Hauler Date
Sitr�7t�te.AP< of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11/12 System Pumping Record•Page 1 of 1