HomeMy WebLinkAbout- Septic Pumping Slip - 453 FOREST STREET 1/22/2019 Commonwealth of Massachusetts
- City/Town of No. Andover
__. . System Pumping Record
_.. W Form 4 j
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 r
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15,351.
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A. Facility Information
Important:when
illlfiing out
forms
rcomp s 1. Location*
Systemw_...
use only the tab �..� - _....
key to move your Address
cursor-do not. No. Andover MA 01845
use the return ....... .. ..... _
key. CityfTown State Zip Code
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2. SystemOwner:
.. .__ _.._... �_.— ._..._ .... �...-.w_ ----------
Nam
eMn
Address(if different from location)
City/Town State Zip Code
........- _...
Telephone Nuniber
B. Pumping Record ,r
1. Date of Pumping _D - -' 2. Quantity Pumped: Gal Ins
3. Component: ❑ Cesspool(s) eptic Tank ® Tight Tank ❑ Grease Trap
❑ Other(describe): — -
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:6"o
6. Syste dumped By:
Na e Vehicle License Number
Stewart's�Pt
58 So. Kimball St., Bradford,MA
_ _ _.�.
Company
7. 'Location wh re contents were disposed:
20 So, Mill t., Bradford, MA _.. ........____.... __.
S ure of Mauler Date
ogn
i
__.._, ._..... ..._ _ .............._..� _.. __ --------------_
Signature of Receiving Facility(or attach facility receipt) Date
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