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HomeMy WebLinkAboutSeptic Pumping Slip - 267 OLD CART WAY 6/7/2018 f Massachusetts aLxa l —_ w fit✓�v�, x .._. .j� City/.iV.oV'n of �"fie. Andover, MA a € i1II Pumping ec r ornr� Pm r1E1' Fre :> pi,ovided thi ,form for use by local Boards of Health. Other forms may be used, but the ij"rita� i rust be suosta ntially the same as that provided here. Before using this form, check with your locr.l t3 r of �-!o'Ilth to d6tf.rrnine 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 ,accorcaai o,e with 310 CIVIR 15.351. l � Y'L m v;i o VI b Important:When filling oui forms Location: on the co,-rof>uter, r f use only Ehe tabGt �CGy �ifG(t�J key to rnrcive your cursor-du not ,;a EOC�C!cVt' MA use the return _._. . key. if,'i ,',l'l State Zip code 111 2. ` �, �,w:ri.Own er: V/v- ve R f--'- Addres�,s(if different from location) cky£1"ov"'a State Zip Code Telephone Dumber 1. I ,Le, car Pumping Date 2. Quantity Pumped: Gallons 3. Component: Cesspool(s) /Kj, Septic Tank M Tight Tank © Grease Trap FJ Other (describe): __._._....... .........._. _ _ _.... 4. PiflovK3nTee F=ilter present? F� Yes -•.No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. Syyterii Pur✓ape By- Name �> Vehicle License Number S�ewaffs Septic 58 So. Kimball St. Bradford,MA c;a�,prany 1. i..ocei'tion where contents were disposed: 0 So, Mill St., Bradford MA _ ......... ...w. _ .........._. _........ .. _..._................ inature of Hauler Date &�jn,nluro of Receiving Facility(or attach facility receipt) Date t5form4.cicce 11/12 System Pumping Record•Page 1 of 1