HomeMy WebLinkAbout- Septic Pumping Slip - 149 SUMMER STREET 1/22/2019 Commonwealth of Massachusetts
City/Tern of o. Andover � � �
Systemin card '
Farm 4 �, ,r,
DEP has provided this form for use by local Boards of Health. Other forms may be used, bufthi
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 15351-
A.
Facility Information
Important:When
filling out fortes 1. System Location:
on the computer, ,
use only the tab 0 ,
key to move your Address
cursor-do not No.Andover MA 01845
use the return City/Town key. State Zip Code .
2. System Owner:
Name
Address(if different from location)
city/lbwn State Zip Code
Telephone Number
B. Pumping &cord
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) deptic Tank ❑ Tight Tank ❑ Grease Trap
® Other(describe):.
4. Effluent Tee Filter present? ❑ Yes ®y No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
C
6. System Pumped By: � .
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
i
7. Location where contents were disposed:
20 So.• ill . Bradford, MA
Sigfia ur f Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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