HomeMy WebLinkAboutSeptic Pumping Slip - 259 GRANVILLE LANE 7/9/2018 Commonwealth of Massachusetts
RECEIVED
City/Town of No. Andover, MA
J U L 9 2 0 18
System Pumping Record
Form 4 7'OWN 0-NOR111 ANDOVER
HEAUH DEF"ARMENT
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 as that 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 date in
accordance with 310 CMR 15.351
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ._ 1259 _1(5.'11_140
key to move your Address
cursor-do not North AndoverMA 01945
use the return --------
key, City/Town State Zip Code
2. SysteM, Owner:
rab
Name
Address(if different from location)
--- ------------ . ..... .......- ------- ---------------------------------------
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ...... 2. Quantity
Date Gallons
3. Component: ❑ Cesspool(s) [4-99ptic Tank F-1 Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? ff_<s"E"1No If yes, was it cleaned? ffrl-e-s "M No
5. Observed condition of component pujZped: c-1
............
6. S gtrnrumped By:
7 T
Name Vehicle License Number
,.Stewart's Septic 58 So, Kimball St, PradfordMA
6omp"an'y_, __
7. Location where contents were disp9spd:
20 So._rv1Ill St Bradford,,NrA"
Date
Signature of Receiving Facility(or attach facility receipt) Date
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