HomeMy WebLinkAbout- Septic Pumping Slip - 62 WILLOW RIDGE ROAD 5/8/2019 PlYilo wIN EE
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Commonwealth of Massachusetts
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r � System PumplMg
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Form
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DEP
has provided thilis fora for use local Boards ofHealth. Other forms may be used, but the
information r must be substantially the same as that provided bare, Before using this f rm check with your
local Board of Health to determine the form they use. 'The System Pumping Recordmust,be submitted itte t
the local Board of Health or other approving authority within 14 days from the pumping date in
A. Facility Information
important:When
filling out forms 1. System Location:
oil,the computer,
use only the tab ........... tu
n
key to move your Address
cursor- not . Andover0 1845
use thereturn .. .. ...,. _
Clt /T+ rn ,Mate Zip Code
tab 2. System Owner-
6e,i/ e.
Name
Address(if rent,from location),
City/Town State Zip Code
Telephone Number
B. Pumping Rec �
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T. Date of Pumping2. Quantity Pumped-, ..�
Date Gallons
3. Component: C ss c ll s �Septic Tan Til"ght Teak ! Grease Trap
El' Other(describe) .,.. , . W_,..._.
4. Effluent Tee Filter resent Yes l if yes, was it cleaned Yes 0 No
5. Observed condition of comp,o;ne
6. S st r a
Narne VehicleLicense Number
St w rt's Septic 58 'So. Kimball St., BradfordMA
..........
Comipany
7. 'Location where contents were disposed:
20 So.. Mill St., Bradford, MA.
Si a auler Date
Signature of Receiving iilit (or attach facility receipt) t
1
t5forr . + o I /12 ,system Pumping record#Page 1 of 1