HomeMy WebLinkAbout- Septic Pumping Slip - 356 RALEIGH TAVERN LANE 5/8/2019 9Jid'�If/59U
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uommonwealth o ss c etas
City/Town Andover
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System Pumping Record
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DEP
has, provided this form for use by local Boards of he l l . Oth r forms may be used, but the
information
s ,be substantially the same as that provided . Before using this form, check with ou r
local Board f Health to et rr ine the form they use. The System Pumping Record must be submitted to,
localthe Board of'health or offer,approving authorifty within 14 days from the pumping date in,
accordancewith 3101 +AMR 15.351.
A. Facility Information
Important:,When
filling out forms 1. System catll :
on'the computer, _m
mm
use only the tad
key to move your Address
cursor,-do not
No. Andover MA 01845
use the return
key* itl�r� State Zip Code
1
2. System Own rM
-e
7
�w
m
Name
I
Address if different from location)
City/Town City/Town State Zip Code
Telephone Number
r
B. Pumping Record
4000
Lo-
11., Date of mping "V m r. ntity
DateGallons
' . Component: El Cesspool(s) Septic Tank 0 Tight,Tank El Grease Trap
Other(describe)-
4. Effluent Tee Filter resat Yes 0, No If es, was if cleaned? El Yes No
M Observed condition of component pumped:
6. System Pu ed By:
Name Vehicle License Number
Sf w is Septic 58 So. Kimball St., Bradford,MA
Company,
'. Location where contents were disposed-
20 S . Mill St,4 Bradford, MA
L/ 91
K21
w '
i ? eider Date
Signature Receiving ilia
r attach facility recelpt) Date
i
t5form4.d * 1 2 System Pumping Reclordo Fags I of I