HomeMy WebLinkAbout- Septic Pumping Slip - 119 DUNCAN DRIVE 11/15/2018 Commonwealth of Massachusetts
City/Town of No. Andover
System pin eo r
Farm 4
1
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.
i
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, C:
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:
rob
Name _ on . ........
..._".
mhrn
Address(if different from location)
City/Town S#ate o
Telephone Number
B. Pumping Record
JJ
1. Date of Pumping Dt ❑Quantity Pumped:
Gallons
3, Component: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye �,� No 71fyes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of cornpone t pump" d:
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6. System Pumped By- �
Name Vehicle License Number ---.._.____
Stewart's Septic 58 So. Kimball St. Bradford,MA
Company .__
7, Location where contents were disposed:
rIgnature
ill St., rd, MA
f Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date __
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