HomeMy WebLinkAboutSeptic Pumping Slip - 46 OXBOW CIRCLE 7/9/2018 crrm�it,,)nwe lth of Massachusetts RECEIV
ij-' f Fern O Andover, MA
Pumping eco
Fort w W SIM � �� �4 IN�� O VE,
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DEP h,. provided thif7,form for use by local Boards of Health. Other forms may be used, but the j
irrror I n:atiE�re must be substaritially the same as that provided here. Before using this form, check with your
Pccsl r�� )f tc datermirie the form they use. The System Pumping Record must be submitted to
the loo;al i.�k) and of Health or other approving authority within 14 days from the pumping date in of
accornarica with 310 CN/IR 15.351. J
lmponlanc When
filling o&�:dans E. ` LC7CAJOI :.
on the r.OETIPUter, ( � /�
use only the tab _ ()j( Vll l
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key tornova.`11your
cursor-do not
[10,A;i MA
use the retuj n
key. r //1 State Zip Code
, Owner:
rea i
(Ji different from location) -
Cir i'�,wv� State Zip Code
Telephone Number
—
o, L�)r,lrrlph7g -dat11 e , 2. Quantify Pumped: Gallons
�3. r �r'Q x�i rr rIt: ��� Cesspool(s) Septic Tar7k ❑ Tight Tank ❑ Grease Trap
�i or (describe): ...... ...... _..
Tee Filter present? -1 Yes [ No If yes, was it cleaned? [IYes ❑ No
r;ondiJon r ampo nt pumped:
i
6. Pfj bpC d By:
Vehicle t.lo ��.� I
ense Number
`erAic 58 So, Kimball St., Bradford,MA
7I r; where contents were disposed: I
;�.,. 'viill ,a ., Bradford, MA _
E.0 �i ealr,r Date
s a� c:r,a��oret�FF,�,c;ihiy or attach facility .....
r ( y reCeipk) Dake
t5forn)?Ldors- '11112 System Pumping Record d Page 1 of 1