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HomeMy WebLinkAbout- Septic Pumping Slip - 144 ROCKY BROOK ROAD 1/22/2019 , Commonwealth of Massachusetts City/Town Of No. Andover � System Pumping Record Foam 4 vp1I� �� 1t 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 . t� 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 t5form4.doc•11/12 System Pumping Record Page 1 of 1