HomeMy WebLinkAboutSeptic Pumping Slip - 53 OLD CART WAY 6/7/2018 of MassachusettsV V Ot �' O. Andover, A
VisdRecord7 ' �
DEP iarovided this form for use by local Boards of Health. Other forms may 1p,9,10b
must be substantially the same as that provided here. Before using this form, check with your
loc^I )f°-loalth to data rmine the form they use. The System Pumping Record must be submitted to i
the local Board of Health or other approving authority within 14 days from the pumping date in
accoio,:wcc,with 310 CMR 15.351.
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lmportan'c When
filling ori �urns ` __C7 cltIUY1:
on the curr ,puter, ,r^
use only the tab C9(d (716–rf toa
key to move your /tr
cursor-do not �,c„ ^ ,`,nC'.over' MA
use the return — ...
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key. C. f, ; State Zip Code
✓ 11 ;?. ���� Owner:
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iocation)
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C.,h'.y!I�avvn State Zip Code
Telephone Number
LSI L""t a`c.,c)r
iPUmt)inggate 2. Quantity Pumped: Gallons _
3, r Tight Tank Grease Trap
");aher(describe):
A, l..ce l filter presertt? ❑ Yes ""No If yes, was it cleaned? ❑ Yes ❑ No
C;. d coo ci Cion of component pumped:
6. lie E3
a.�
Vehicle License Number
Septic 58 So. Kimball St., Bradford,MA
i
=,c r I whore cont(.,mts were disposed:
vrili SL., Ekadfgid, IVIA
d
a �
�� no r Hmder Date _
[`,icility(or attach facility receipt) Date
t5forrn,',Aov.µ 11/12 System Pumping Record•Page 1 of 1