HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 5/8/2019 (7) � ! IVEIII
Commonwealth of Massachusetts,
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City/Town No. Andover
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System Pumping
Form 4
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DEP has provided this form for use by local Boards of Health.. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this former, check with your,
local Board of Health to determinethe form they use. The System, Pumping, Record must be submitted t
the local Board' of Healthr other approving authority within 14 days from the pumping date in
A, Facifity information
Important:When
filling out f►rms 1. System Location:
on the rutr, W1 I V iL/
,.
use only the tab W/f, �71�1 `
key to move your Address
cursor not . Andover 5
use the rtrn ,,,�M..� rvmmm . ...m,. . ... ...„
City/Town State Zip Code
2... System Owner:
Ish
Name
Ad
� r �cif different from location)
................................
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Cit fT lwn State Zip Code
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Telephone Number
B. Pumping Record
1. Date of' " i �.. 2. uantit Pumped'. . , .
Date Gallons
3. Component- Cesspool(s) Septic Tank Tight,Teak [?r6rease Trap
Other(describe): _...
Effluent Tee Filter rant" "Yes NCB if yet, was It lean Yes E] No
5. Observed condition f component pumped:
1 . System Pumped By:
Name Vehicle License Number
Shaw rt's SepjJc 58 So. Kimball St., Bradford,CIA
Company
7. Location where contents were disposed.
20 S . Mill ,fit., Bradford, MA
r
Signature f l er Cate
i
SignatUre of Receiving Facility(or attach facility receipt) Date
t; f r , e 11/ 2 System Pumping Record Page 1 of 1