HomeMy WebLinkAbout- Septic Pumping Slip - 507 SALEM STREET 5/8/2019 vra��t
f
uommonwealth of Massachusetts
p
City/Town
of No., Andoves
u lµ t
p 1
R
�
u
m �� II II N
°14f1 phl' N ij AJ V( �q)
w FI
{I 4 Ni,:'a';II ,'V ash ry
Form 4
�IY
I
s provided this,fora for use by local Boards of Health. Other forms s may be used, but the
information rust be substantially th el seas as that provided hers. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record rust be submitted t
the local Board of Health r other approving authority itl ire 14 days from the pum inn date yin,
accordance with 3 !CM R 15.351
A. Facility Information
Important:When,
filling out forms 1. SystemLocation:
on the computer, � M
3cr .
u.� onlyt' tali �.
key to move your Address
cursor-do not . Andover MA 0,1845
Use the return
Ie City/Towntit Zip Code —-------
14b
2* System Owner'-
t
I
Na
LAI,
different.Address,(if from location)
1
City/Town State Zip Code
Telephone Number
K. Pumping
w
at m �n 2. Quantity pad:
It Gallons
3, Component: Cesspool(s) Septic Taal Tig t Taal Grease Trap
El Other(describe): ..-.m ..
4. Effluent Tiee Filter present? Yes No If yes, was it leaned? Yes Igo
5. Observed condition of component pumped:
r
6. Sys m Plumped By.
,Lu�
gam
I
e Vehicle License Number
St wart's 3 tic 518 Sa. Kimball St, Bradford A
Company
. Location where contents were disposed.
Signature of Hauler Date
Signature of rlrn Facility r attach facility rlpt It
t t rr , o 1/ 2 System,Pumping Record 1 e 1 of 1