HomeMy WebLinkAbout- Septic Pumping Slip - 1320 OSGOOD STREET 5/8/2019 mI o n w uaa lth of Massachusetts,
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City/Town
Andover
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Pumping
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DEP has provided this form 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 fora, check with your
local Board f Health to determinethe form they use. The System i
the local Board of Health or other approving authority within 14 days from the pumping date in
X Facillity Informalti I on,
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Important-,When
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on thecomputer,
use only the
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City/Town Zip Cody -------
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2. System Owner:
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Name
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Address if wft r nt from location)
City/TownState Zip Code
TelephoneNumber
B,, Pumplong Record
1. Date of Pumping
'001Date . J Quantity Pure , ......
/o
Gall ns
IComponent: � Cl ss l(s), �� 'Septic Teak E] Tight Tank Grease Trap
El' Other(describe)- "",0-1-1
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00
1011,0/ 00010'
4.
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Effluent Tee Filter present? Yes Ej If yes, was it cleaned'? Yes 0"'ONo
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5. Observed I II i I 1',a of component Sri"'t',I J`u
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60
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S ,,,slem Pumpedr
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Naas Vehicle License Number
Stewar's Septic 58 So. Kimball St., BradfordMA
Company
'. Location where contents were disposed:
20 So. �A
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Sign tUr of Heeler Date . E
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Signature,of Receiving Facility, r attach facility receipt) Date
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