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HomeMy WebLinkAboutSeptic Pumping Slip - 270 BRADFORD STREET 7/9/2018 Commonwealth of Massachusetts r�� City/Town of No. Andover System Pumping Record Farm 4 �a��h�Q�u��b l�k��i I n�AW,)'0VER 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 D /70 f�AA4V ... _..__.... key to move your Address cursor-do not No. Andover MA 01945 use the return _ _ __ _ ....__. key. City/Town State Zip Code 2. System Owner: Name reaan Address(if different from location) City/Town State Zip Code Telephone Nan ber B. Pumping Record / I. Date of Pumping 2. Quan#i#y Pumped: 11 Ga..llII Date ons _......... 3. Component: ❑ Cesspool(s) E9,18eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? © Yes ❑ No If yes, was it cleaned? © Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: f Name Vehicle License Number Stewart's Septic 58..So. Kimball St., Bradford MA----- Company _ i 7. Location where contents were disposed: 20 So. Mill St., Bradford MA _. ........... _......... _..w._ Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record-Page 1 of 1