HomeMy WebLinkAbout- Septic Pumping Slip - 144 ROCKY BROOK ROAD 1/22/2019 , Commonwealth of Massachusetts
City/Town Of No. Andover �
System Pumping Record
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DEP has provided this form for use by local Boards of Health. Other forms 4y be used, but the I
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
filling out forms 1. System Location:
on the computer, ^
use only the tab ttt!t:�
key to move your Address
cursor-do not No.Andover MA 01845
use the return Ci !Yawn
key. tY State Zip Code .
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2. System Own r:
Name —
regm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping )Da/ ' 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 If yes, was it cleaned? ❑ Yes El No
5. Observed condition of component pumped:
6. Systo" Pumped By:
UP K
Name' vehicle License Number
Stewart eptic 58 So. Kimball St., Bradford,MA
Company
7. Locatiohwhe contents were disposed: f
20 S Mill St Bradford MA
Signat re auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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