HomeMy WebLinkAboutSeptic Pumping Slip - 52 OLYMPIC LANE 7/9/2018 f (Massachusetts
Crity Q RECEIVED
(w,� of e. Andover, MA
4
b morncPt,�rnping Record
3 _
OWN OF N Fol 8 ANDOVER
DEP tr:a:; provided this forrn for use by local Boards of Health. Other forms may
iurtorrnzA,0,k i7°iust be substantially the same as that provided here. Before using this form, check with your
loc,r l ", - s': ')f to d1Utc.rmine the form they use. The System Pumping Record must be submitted to
the loc a= i:se:aard of Health or other approving authority within 14 days from the pumping date in
accoro.,,,ric°.e with 310 CMR 15.351.
lmporc:zs VVhen
filling(xcu . fms
on the a rnputer, oo
use oly the ab -)-
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keyto move your
cursor-donot .lu Ar�CC7'V i' MA
use the retui C1 ._._. _.. — _.
key. 'r State Zip Code
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�.dif(er'arla ra'om location)
State Zip Code
Telephone Number
� a. `` u ���.f )'
1. ):.�t; Of N'urrrpinct 2. Quantity Pumped: /V-5 -
Date Gallons
3. C ofy i:r+:rrient: F1 Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
.1
01"her(describe): _......,.. ......��_�._........ ... .... .._. _......
4. l hi'tiWsriL"Cee Filter present? Yes ❑ No If yes, was it cleaned? fff Yes ❑ No
condi ion of component �mped:
I'
6. SVsirarrm l='gum y: ,,0
Name Vehicle license Number
Stewart
's Septic 58-So. Kimball St. Bradford,MA
_....
Co p my
7. Location aiion where contents ere disposed:
cs..ltillill
St., Bradf6
r ""rd, fVIA
J11TETU
111" uler Date
Siyta ature:of Receiving Facility(or attach facility receipt) Date
t5form4.doc� 11112 System Pumping Record-Page 1 of 1