HomeMy WebLinkAbout- Septic Pumping Slip - 91 VEST WAY 5/8/2019 I oyyi
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uommonwealthuo%f Massachusetts
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City/Town No. Andover
System Pumping Record
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DEP has Provided this fora for use by local Boards of Health.. Other forms, may be used, but the
information rust be substantially the same, as that provided here. before using this form,, check with your
local Board of Healthto determine the fora they use. The Systemli Pumping Record rust be submitted t
the local Board of Healthr other approving authority within 14 days from the pumpingdate in
accordance witl 310 C M R 15.35
A. Facility Informati
Important:When
filling out forms 1., System;; Location:
on the computer, ,a
use only the tab
1
key to movel your Address
cursor not . Andover. MA 01845
us the rturn �tT
key
® wry; State Zip Code
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2. System Owner:
Name
ab
Address if different from location!)
State Zipl Code
Telephone Number
B. Pumping Record
11, Date of P:umplingro . m m 2. QuantityPumped: ... .............
3. Component-,
Other escri le): ._,m_.._.. .......
4. Effluent Tele Filter present? El Yes,,Q No If yes, was it cleaned?, Yes N
5. Observied condition of component pumped.,
6. System Plumped
e", J� ;�� t
Name ��.�,��m. Vehicle License Number
Stewart's §WIc;58 So. lei ball St., BradfordMA
Company
. Location where contents were disposed:
20 So., Mill St.,, Bradford, l l
1
S(gn,b'Cure of Hauler Date
Signature of Receiving Facility r attach facility .._.
i
snit, Date
t5form4,,idocls 11112 ,System Pumping Record Page 1 of