HomeMy WebLinkAbout- Septic Pumping Slip - 127 ABBOTT STREET 12/12/2018 |
Commonwealth
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System Pumping Record
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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 hero. 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 31OCW1R15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your AUUpeoa
cursor'do not
N— Andover MA 0184
uaetxeretum
key. City/Town state Zip Code
2. System Owner:
Name
Address(if different from location)
uty//own State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2� Quantity Pumped:uo�a u�n wnnp� � Gallons
3. Component: Fl Ceaspoo|(a) [2~Septic Tank F� Tight Tank El Grease Trap
El Other(describe):
4� Effluent Tee Filter present? [7 Yes Fl No ]f yes, was |tcleaned? El Yes R No
5� Observed condition of component pumped:
6. System Pumped By:
-�-ame ' Vehicle License Number
Company
7. Location where contents were disposed:
20 So. N1i|| St Bradford, K8
Date
Signature of Receiving Facility(or attach facility receipt) Date
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