HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 7/9/2018 Commonwealth Massachusetts
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City/Town +�/ No. Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same authat provided here. Before using this form, check with your
local Board of Health to determine 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 deba in
accordance with 31UCMR 16351.
RECEIVED
A. Facility Information JW
Important:When - - -
018
filling out forms 1. System
on the computer, I-jEALT14 DEPARTMENT'
use only the tab
key tomove your Address -
cursor-do not
N-� Andover
unerhamtum '`
key. ugv/mmn State Zip Code
2. System Owner:
Name
Address(if different from location)
city State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3, Component: El Cesspool(s) F� Septic Tank R Tight Tank F-T'&ease Trap
[l Other(describe):
4. Effluent Tee Filter present? 0 Yea No |fyes, was itcleaned? Fl Yea El No
5. Observed condition ofcomponent pumped:
0. System Pumped By:
me �7 Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,N1/\
Company
7. Location where contents were disposed:
�O So. k8i|| �t� Bradford, [NA
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