HomeMy WebLinkAbout- Septic Pumping Slip - 303 BERRY STREET 5/8/2019 Cx uommonwealth f ss c husetts
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City/Town No. AndoverSystem
Pumping
Record
Form 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 fora, check with! your 1
local Board of Health to determine the form they use. The System mpin Record must be submitted to
the local Board of Health or other,approving authority within 14 days from the pumping date in 1
accordance with 3 C�I IR ��5,351.
A. FacilityInformation
Important:When.
filling out,forms 1. System Location,
on t he computer,
use on
ly the,tab
key to move your Address
cursor-do not , Andover MA 5
use the retkey. urn "fit / o,wn State Zip,Code
m
9
2. System Owner:
zName
i
Address it'�_..
1
ditfcrent from location)
City/Towneo
State Z,ip Code
Telephone Number
B. Pumping Re�cord
1 Date of Pumping 2., Quantity Pumped:
Date Gallon
Cess,pool(s)
3. Component El"'�Se pt i c,Ta n k El Tight Tank Ell Grease Trap
Other(describe)-'
. Effluent'Tee Enter present? Yes [9111�NoIf ls, was it l a e ' Yes, No
5. .served condition of component pumped:
_w
J
.............
6. System Pumped By-,
. ...... _ _ „„ w... ...
Name Vehicle License r
Stewart"stiq 5 S . Kirhii St.aI Bradford CIA
�N �
Company
1
:
'., Location where contents were disposed:
20 So, iNi St.„ B,radtqrd�
�r
I
� � I
Signature of Heeler Date
SignatUre of Receiving Facility r attach facility receipt) Oahe
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