HomeMy WebLinkAbout- Septic Pumping Slip - 1077 OSGOOD STREET 5/8/2019 i1a nl CVCI"�
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Commonwealth Of Massachusetts
City/Town of No. Andover
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Sys
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.,r Form 41
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" has provided this form for use by local Boards of Health. Other forms,s may be used, but the
information must be substantially the same as that provided here® Before using this form, check with your
local Board f Health to determine the fora they use. The System Pumping Record must be submitted t
the local Board of Health or other approving authority within 14 days from the pumping date in
A, Facility Information
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filling out forms 1. System Location
on the computer,
,e only the t
r to move your Adidres,s
cursor-do niot No. Andover M 01845
use the return ., ��. ,.�...� � ��. �
k City/TownS ZipCode
2. System Owner:
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Name
Ulan
Address if different from location)
City/Town State Zip Code
Telephone Number
B. Pump,nig Record
1. Oahe f ' roping ��. ��..�� Quantity
�.� � �.. ��, .w ..� � �
Date Gallons
3. Component: Cesspool(s) El Septic Tank El Tight Tank, o cease Trap
Other (describe):
., EffluentTee Filter present? Yes No If yes, was It cleaned' Yes N
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
Stewart"s Septic 58 So,. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 S . Mill St., Bradford, MA
................ ......................
Signature of Mauler Cate
Signature of Receiving Facilityr attach facility recent), Date
t5f rm .dr e 11/12 System Pumping Record'o Page I of