HomeMy WebLinkAbout- Septic Pumping Slip - 58 PADDOCK LANE 9/21/2018 Commonwealth of Massachusetts
City/Town of No. Andover MA
System Pumping Record
Form
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
key to move your Address
cursor-do not No. Andover MA 01945
use the return _.._.__. ..................
key. City/Town , State Zip Code
2. System Owner:
rab
........... ...._. _.._ ......_.._.._
Name
rufiun
Address(if different from location)
_...... ---------- ......._._...
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ._-.-- �_ 2. Quantity Pumped: Gallons
Date — -- _
3. Component: ❑ Cesspool(s) QXeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
M
6. SystemPumped B
LA 0
Nae Vehicle License Number
Stewart`s tic 58 So. Kimball St., Bradford,MA
Company
7. —Locatioij where contents were disposed:
20 So, Mill St, Bradford, MA
a re of Hauler Da#e
Signature of Receiving Facility(or attach facility receipt) Date
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