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HomeMy WebLinkAbout- Septic Pumping Slip - 210 FARNUM STREET 1/22/2019 Commonwealth of Massachusetts City/Town of No. Andover System um ire Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the j 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 I Important:When filling out forms 1. System Location: on the computer,use only the tab tof-�'ro u VVI key to move your Address cursor-do not No.Andover MA 01$45 use the return — — key. City/Town State Zip Code 2. System Owner: for Name --— �eArn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record !' 1. Date of Pumping pate C 2. Quantity Pumped: G ._ C✓� 3. Component: ❑ Cesspool(s) ©--9 ptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): _._.._a - 4. Effluent Tee Filter present? ❑ Yes ��fp�� If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped- 6. System Pumped B Name -Vehicle License Number — Stewart's Septic 58 o. Kimball St., Bradfard,MA Company 7. Location where contents were disposed: 20 So. Mill St + dfl�dr - -- Signature o Hauler Date Signature of Receiving Facility(or attach facility receipt) Date i t5form4.doc•11112 System Pumping Record-Page 1 of 1