HomeMy WebLinkAboutSeptic Pumping Slip - 10 HAWKINS LANE 7/9/2018 Commonwealth of Masse Chusetts
T City/Town of No. Andover
System Pumping Record
� V X018
l
Form 4ti 4@°u I i "dV. Fl:°u'
i1Y) GQuD fIP i(11 i R
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 j
Important:When
filling out forms 1. System Location:
computer,on the
use onlyhe tab ( /
C.) r
key to move your Address
cursor-do not No. Andover MA 01945
use the return _. _.... ...�
key. City/Town State Zip Code
2. System Owner:
r�5 1 /
Name _.... _.__
19 AUR
Address(if different from location)
City/Town State Zip Code
Telephone Number
_............
B. Pumping Record
1. Date of Pumping "~ d 2. Quantity Pumped: f �
Date Gallons
3. Component: El Cesspool(s) Nlwpfic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? �es No
5. Observed condition of component pumped: 7
6. Syst Pumped y:
r"
Nam Vehicle License Number
Stewart' otic 58 So. Kimball St., Bradford,MA
Company
7. Lo
Y,pation where contents were disposed:
QSo. M' St., Bradford, MAre of Hauler Date
_..—... .. _...
Signature of Receiving Facility(or attach facility receipt) Date
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