HomeMy WebLinkAboutSeptic Pumping Slip - 545 WINTER STREET 7/30/2018 �amm
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Commonwealth of Massachusetts �
"ty[Town of r , TL
Sy
stem Pumping Recor018
d .Mi DE,,U�.I ANDOVER IEN'T
Form 4
DBP 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 youi
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
Impartmnt;When
filling out forms 1. System Location;
am M computer,
u oriiy.the tab )' �� L
0 to move your Address
we 1, ;return
Cltylrowm State Zip Code
2. System Owner:
s
AlYi
Name
tw
o-
Address Of different from location)
;.r
Citylrowm
Stats Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping /42. Quantity Pumped: )o
Data
Gallons
3. Component: ❑ Cesspool(s) ErSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
S. Observed condition of component pumped:
6. System Pumped By:
Nara Vehicle Ucense Number
Company
7. Location were contents were disposed;
..
Signature of Haulq6 Data
Signature of Receiving Facility(or attach facility receipt) Date
t5tomt4.doc•19/12
4 System Pumping Record•Page 9 of i