HomeMy WebLinkAbout- Septic Pumping Slip - 40 OXBOW CIRCLE 5/8/2019 I
, Massachusetts
..owI ol h
L Ity/Tow
C n of No. Andover
System Pumping Re
r qI
w,
ue`P
E hasprovided this form for use by local Boa,rds of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this fore, check with your
loyal Board of Healthto determine the fora they use. The System "u m i g Record rust be submitted to,
the local Board of Health or other approving authority within 14 days from the pumping date in
a ccordance with 310 C M R 15.35 1.
A. Facility Information
Important„When
filling out farms 1. System Locati,on
n the computer,
I
use only the tad
key to move your Address
cursor-do not, . Andover 5
use the return rr� City/Town.,.,� �.. ,.,, .,..... . mm.. . .... _ Ott w_ m.�.
key,.
Zip Code
2. System Owner:
Ir
Name
Address if different from lti! rr
State Zip Code
Telephone Number
B. Pumping Record
q,
1. Cute of Pumping 1_ 2., Qua wtity Pumped:ItGallons
3. Component: C ss IN s peptic Tank El Tight t Grease Trap 1
El Other (deiscribe),i-,
i
1
. Effluent Tee Filter resent `s, [!!I Nio If yes, was it cleaned? El Yes, [:1 No
5. Observed condition of component pumped",
6. System Pumped y
X�,,a, e Vehicle License Number
"tewart's Se tic 58 So. Kimball St., Bradford,MA
........... m .........
Company
. Location where contents were disposed:
sad
20 So. Mill St., Bradford, MA
Ana ure auler late
Signature of Receiving Facility r attaO facility receipt) late
t f rm .. -, 1'1/12 System Purnping Recordo Page 1 of