HomeMy WebLinkAbout- Septic Pumping Slip - 221 FARNUM STREET 1/22/2019 �, Commonwealth of Massachusetts
ry _. ___ r City/Town of No. Andover
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System Pumping Record �� f w
Farm 4
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
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
filling out forms 1, System Loc Location: tt
on the computer,
use only he tab — ...._..... ....�_ - r r,� ,. .-.- .._..
key to move your Address __.......
cursor-do not No. Andover MA 01845
use the return - _.. ....... _— ......._....
key. City/Town State Zip Code
2. System Owner:
rab
Name ....... __....
�rnun
.......-. ....__... __._._...._...__...
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date _. ?quantity Pumped: Gallons
___._
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _......__. ..........
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componentPumped:
6. Sysfe—nm)NITped By: � _...
Name Vehicle License Number
Stewart's Septic 58 So Kimball St,, Bradford,_MA
Company
I
7. Location where contents were disposed:
,20-So:-.-Mill St., Bradford, MA t
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Signa�oofafe Date
Signature of Receiving Facility(or attach facility receipt) Date
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