HomeMy WebLinkAbout- Septic Pumping Slip - 1797 SALEM STREET 10/17/2018 Commonwealth of Massachusetts
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- Pumping
Form
DEP has provided this form for use bv local Boards ofHealth. Other forms may be used, but the
information must be substantially the same aathat 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 |noa| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCK4R15.351.
A. Facility Information
Important:When
filling 1. Syste
on the computer,
use only the tab /0'79
key to move your xuU��
-----
cursor'do not
No� Andover K4
use the natum
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
- ��) .1/k
41
1. Date ofPumping Quantity
o��a — � Gallons
3, Component El Cemspmo|(a) V' SepticTank Fl Tight Tank F7 Grease Trap
0 Other(describe):
4. Effluent Tee Filter present? n Yes 2' No If yes, was it cleaned? E] Yes Fl No
_. Observed condition of component pumped:
8. Syst Pumped
Name Vehicle License Number
Stew rt's Septic.58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
2OG
tignature of Hauler Date�
Signature nf Receiving Facility(or attach facility receipt) Date
t5form4.doc'1 Ill System Pumping Record^Page 1uf1