HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 10/17/2018 (3) Commonwealth of Massachusetts
x City/Town of No. Andover
System Pumping Record
Farm 4
DEP has provided this form for use by local Boards of Health. Other forms4 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.
1
A. Facility Information
Important:when
fill ing out forms 1. System
--Location: /
on the computer, c � 61 ( �
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return _.-.._
key. City/Town State Zip Code
2. System Owner:
Name
Arun
Address(if different�from location)
City/Town State Zip Code
_ Telephone Number _
B. Pumping I�ecord _�.._
1. Date of Pumping Da 2. Quantity Pumped: ea Ions
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe): '" � °'
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pu ed By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company _..-
7. Location where conte disposed: j
20 So. Mill S radford, J
Sig ur er Date
Signature of Receiving Facility(or attach facility receipt) Date
i
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