HomeMy WebLinkAboutSeptic Pumping Slip - 97 BRADFORD STREET 6/7/2018 C uv
of Massachusetts
-i of No. Andover, MAJUN
Sy,,,, Pumping Record
Mt JP i Ot° ANDOVER
favr nr�, I6�a'�k,I'ii& Jda�tb&'(tL., f
DE-P tp,ovided thif7, orm for use by local Boards of Health. Other forms may be used, but the
ififoi'r.9atioj a must be su>) tantially the same as that provided here. Before using this form, check with your
loc��l I of!-Ie a!th tL d_te!-mine the form they use. The System Pumping Record must be submitted to
the local i3oard of Health or other approving authority within 14 days from the pumping date in
Gfccoroarrcn with 310 CZAR 15r.351.
Importan L:'VVhen
filling OUk'ATrs w€l
�. w.
an tl7c computer,
tAC AtlVll.. .
use ac71y the tab
key to nnov( your
cursor..d�, not
lh/1/s,
use th(�re.^.rn _
key. F .'' i State Zip Code
i( ...
rye �.�
J' (F difforwnd fror-o location)
„
State Zip Code
Telephone Number
1. s �.._.Y.:.... .... ........ .._.......
a� i'ttrrl�>ing2. Quantity Pumped;
Gallons
_ Cesspool(s) Se ti
:�>. r arr��i:>trr,r:�ni:: 1._m ptic Tank ❑ Tight Tank ❑ Grease Trap
t1'i r" (describe): --------------------------------......................... .................
Z(.. Tee c; i=°ilter present? Fj Yes [2""�No � If yes, was it cleaned? ❑ Yes ❑ No
r;ortdit on ext component pumped:
Pi.lMped By:
Vehicle License Number
Sepiic 58 So. Kimball St., Bradford,Nla
wliere contents were disposed:
S
f. Bradford, i
�/
-larder Date
_.._... _. _._.._... - -__ ....... ........
e Rr.G;eiving Facility(or attach facility receipt) Date
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