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HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 3/12/2019 Commonwealth of Massachusetts City/'Town of,No. Andover System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms r>iay 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. A. Facility Information Important:When filling out forms 1. System Location. on the computer, use only the tab ) / /,'" �% m key to move your Address cursor-do not No. Andover MA 01845 use the return _ _.. — .............. key. Cityrrown State Zip Code VQ 2. System Owner; el Name Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record Cie t / c 1. Date of Pumping ._�Date 2. Quantity Pumped: Gallons - 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap ,r Er—Other(describe): 4. Effluent Tee Filter present? © Yes D-1`4; If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped; -- ----- U� 6. System Pumped B Name Vehicle License Number Stewart's Septic 53 So. Kimball St., Bradford MA Company 7. Location where contents were disposed: 20 So. Mill St., Brad ord MA - Signature of Hauler pate Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc^11/12 System Pumping Record.Page 1 of 1