HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 8/8/2018 (7) Commonwealth of Massachusetts FZr,T-C!,',..flVED
City/Town of No. Andover, M
A UG C U 2()1 B
System Pumping Record
TOWN OF iHANDOVriR
Form 4 1 Ui rII IIS 1:)!,�'AR[MEW
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 35�
key to move your Address
cursor-do not No. Andover MA 01945
use the return ...........
key. City/Town State Zip Code
'IOU 2. System Owner:
64 tie-" `N Jo
Name
rensn
Address(if different from location)
.................
City/Town State "49 Zip Code
Telephone r4umber
B. Pumping Record
2. Quantity Pumped:
1, Date of Pumping rt Date Gallons
3. Com bnent: ❑ Cesspool(s) Fj 5_ ptic Tank El Tight Tank Ej Grease Trap
Other(describe): L
4. Effluent Tee Filter present? R YeL[�Ko If yes, was it cleaned? E] Yes ❑ No
5. Observed condition of comb
ponent pumped:
6. Syst!7,Rtiffipecl By:/
ja3 & (,:U11)1`tlu ......
NameVehicle License Number
Stewart's
' Septic 58 So. Kimball St., Bradford MA
Company
7. Location where contents were disposed:
:aO So. Mill St.,/Brpdford, MA
91 -
--2—
ure
Sig of Hauler Date
S1 at
f c
Si at6re of Receiving Facility(or attach facility receipt) Date
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