HomeMy WebLinkAbout- Septic Pumping Slip - 20 CHRISTIAN WAY 5/8/2019 1p
uornmonwealth of Massachusetts �V,Eo
City/Town of No. .Andover ....
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System
Pumping
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DEP
has provided this form for use by local Boards of Health. Other forms may be used, I ut ti>'
information must be substantially the same as that provided here. Before using this form, check with your
local Board lth to determine the fora they use. The System Pumping Record rust be submitted t
the local Board of Health r other approving!. authority within 14 days from the pumping date in
A. Facility Information
Important:When
filling out forms 1. System, Location*
on,the mp t rd
use only the tab r
�... � �.
key to move your Address,
cursor-do notNo., Andlovier 01845
use the return
City/Town
key
A City/Town State_ Zip Code
2. System Owner:
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Name
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Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping
1. Date of Pumping 2. a ntiit Pumped:It ' Gallons
I Component: C ss 1 s. Septic Tank Ej Tight Tank, 0 Grease Trap,
E] Other(describe. m.. ..w.,.„n. ....
4. Effluent Tee Filter rant" Yes 2,"�No If des, was it clam 0 "des N
5. Observe condition of component plumped:
6. System Pumped
Name Vehicle license Number
...... rd, A
,twart s tip 5 ' �� . Kimball St., Bradfo..„
Como n
7. Location where con�t nts were,disposed-
20 So. Mill St., Bradford, M
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Signature of Hauler..
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Signature of Receiving Facility( r attach facility receipt) Date
t5form4,doce 11/12 ;system Pumping Record Page 1 of 1