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HomeMy WebLinkAbout- Septic Pumping Slip - 81 LACONIA CIRCLE 11/15/2018 Commonwealth of Massachusetts City/Town of No. Andover _ System Pumping Record Form 4 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 use onlyon the tab t .., g y i � F fillip out forms System ocatlon � �"� 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 renrn ............... .......... ... Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record__......_ 1. Date of Pumping Date 2, Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) tic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): _....._ 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? © Yes ❑ No 5. Observed condition of component pumped: 6. Sys Pumped B Narhe Vehicle License Number Stewart's 5/e"p is 58 So. Kimball St., Bradford,MA Company "t o 'tion w 7. ca..i her contents were disposed: (Sign 0 SC Mill S , Bradford, MA 119112 r,,... gr o F au er . Date / __... ................ __,_ . ......... .. —...._......, Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1