HomeMy WebLinkAbout- Septic Pumping Slip - 23 WILLOW RIDGE ROAD 12/12/2018 Commonwealth of Massachusetts
City/Town of No. Andover �
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System Pumping Record itniYCf �����,��
Farm 4
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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 t
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, i p�
use only the tab
key to move your Address 1
cursor-do not No. Andover MA 01845
usethe return _...... _ .__.. ...._.._ _......._...__. _....__._ .........__.
key. City/Town State Zip Code
2. System Owner:
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Name _—�.._......_�
Haan
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1 (
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1. Date of Pumping Date 2•A;Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Ftl—Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): r "
4. Effluent Tee Filter present? El Yes �',-"O If yes, was it cleaned? ❑ Yes No
5. Observed condition of component„pumped.
?.. :,..
6 Syst;e mped By r"
❑ue
Name----" vehicle License Number
_Stew art's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
2p So. Mill St,, Bradfor f lA
Signature of au e, Date
Signature of Receiving Facility(or attach facility receipt) Date
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