HomeMy WebLinkAbout- Septic Pumping Slip - 289 STILES STREET 5/4/2019 1
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Commonwealth Massachusetts
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System Pump"Ing Record
TOWN OF KC)"Fit"TH ANDOVER
'A,RTMENT
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has provided this'f rm for use by local Boards of Health. Other forms may be used, but the
information rust,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 ing Record must be submitted tol
the local Board of Health or other approving authoritytin 14 days from the purpling date in
accordance with 3 .
A. Facility
i
Important.,When
filling,out forms I., System cation
on the computer,
use only the tab
. .
key to move your Address
cursor-do not
use the return d
key. Cii own state Zip Colde
2. System Owner.,
1
Name
Address if different from coati
Cfrn Stag Zip Code
a69
s
Telephone Numbe,
B. Pumping Record"
zl- 2. Quantity Pumped*
I., Date of Pumping
Date Gallons
3. Component: E] Cesspool(s) Spit Tank 0 Tight`dank Grease Trap
El Other(descdbe).-
4.
Effluent Tee Filter present , No if yes,was it cleaned? Yes N
pa,5. Observed condition of component pu eld%,,
i
6. System
Na Vehicle License Number
e/l 1)
Company
7, Location where contents were disposed,
Is n of Hadler Date
signature of Receiving Facility r attachfacillity receipt), Date .
p
lip
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t5f rmC le 11/12 System Plumping,Record Page