HomeMy WebLinkAbout- Septic Pumping Slip - 266 LACY STREET 5/8/2019 1
uommonwealth of Massachusetts
ity/Town, of No. Andover,
Aq System
iii�r iPail, J a 9,i
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_ Pumplaing Record
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DEP
N ��N'i 4UYAlu IM aluJ"'W/rIGN 1 j
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has providedthis form for use loll Boards Health,, I Other florins r �� � used,, but the
information must be substantially the seas as that provided here., Befor+ sr this fora, check,with your
local Boar health to determinetheform they use, The System Pumping Record must be submitted t
the local Board of Health or other approving ving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms . System, Location:
N I
on the computer,
use only the tab (jut
Ivey to move your Address
cursor_do not, No. Andover MA 01845
use the return
key, City/Town State Zip Code
2. System Owner*
Narne
e6A
Address(if different from,location),
City/Town State Zip Code
.......................
Telephone Number,
... w
B. Pumping Record
_
PumpingUDO
Date of 1.
4
..�" ;_..N.,:�:.
t�-
Date Gallons
Ej 3. Component: Cesspool(s,) F<Sepfic Tank [:1 Tight Tank El Grease Trap
Other escrileW
4 Effluent Tee Filter priesient El Yes [a"�No if yes, was, it cleaned?, Yes El No
54 Observed condition of component u I e
6. System Pumped
Name
Vehicle
., l License Number
Stewart's Septic�. 58 Soo Kimball St ,MA
Company
7: Location where contents were disposed-
20 So. Mal l St4, Bradford 1"
i t f r t
...m.. m_. ... ....
Signature of Receiving Facility(or attach facility receipt) Date
t for , a * 11/12 Bateau Purniping Record Page 1 of