HomeMy WebLinkAbout- Septic Pumping Slip - 110 FOREST STREET 5/8/2019 p� Y
� ab� Commonwealth Massachusetts
„ CRY/Town o Andover,
System Pumping
1�r i 40}al
Form, 4 h
has provided this t r y for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same, s that provided here. Before using this fora, check with your
local Boar' of Health to determine the form they use. The Systern Pumping Record must he submitted t
r
the local Board of'Health, or other approving authority within days from the pumping date in, r
accordance with 310 CAR 15.35 1.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 0
use only the tab, �n
key to move youir Address
cursor not No. per 5
use to return ....,
key.. Cit [Town ,Mate Zip,Corte
2. System Owner:
C
io
Name
MAP
Address(if different from location)
City/Town
State
Zip Cody
Telephone c ry N um b r...�,,
B., Pumping Record
I. Date of Pumping
Dat 2. Q rat i't " Pumped:
Gallons
3. Component: Cesspool(s) E Tank Ti ht dank �Graasa Trap
El othier('describe)-
. Effluent Tee Filter resent? � Yes lea
' � l ���, was it cleaned?
5.. Observed condition of component pum!peld*
I
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I
I
I
I
,. stem Pumpe By:
Name ' hi'cle License Number
r
,Stewart's Sep 5 S . Kimball St, BradfordMA
Company
Location- where contents were disposed:
i
20 So,. Mill St.� rat M
r
Signature f Hal ' Date
.��... � _.__ r attach fil.���,receipt)
Signature f Receiving Facility �t
t f rm . o 1, /12 System Pumping Record Page 1 f