HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 12/12/2018 (9) Commonwealth of Massachusetts
City/Town of No. Andover '
- System Pumping Record �
Farm 4
DEP has provided this form for use by local Boards of Health. Other forms may be used lout tine
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 0 b1 ) __
key to move your Address
cursor-do not No. Andover MA Q1845
use the return Clt /Town __
key, y State Zip Code
2. System Owner:
Name - _..... _
Address(if different from location)
CitylTown State _ Zip Code
Telephone Number
B. pumping Record
11221YU
1. Date of Pumping sate 2. Quantity Pumped: Gallons
3. Component: El Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
a"Other(describe): —
4. Effluent Tee Filter present? 0 Yes R N If yes, was it cleaned? ❑ Yes ONo
5. Observed condition of component pumped:
lid
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St. Bradford, MA t
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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