HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 6/10/2019 a�rr
Commonwealth of Massachusetts
City/Town, of
r TOWN OF N,C)RITI N R
System, Pumping Record
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Form
DEP has, provided this form for use by local Boards of Health. Other forms may be used, but the
information rest be substantially the same as that provided here. Before using this fora, check with your
local Board of Health to determine the fora they use. 'The System Pumping ecord rust be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
,accordance with 310 C R 15351.
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A.
Facility
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Important When
filling out forms 1. System Loc ti
on the computer, "
key to move your Address
cursor..do not . Andover M 5
use the return
key. pity/Tow n State Zip Code
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2. Satan Owner:
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Name
Address if different from location)
City/Town State f dip Code
Telephone Number
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B. Pumping Record
1 Date f Purnping Dates 2. Quantity Pumped: Gad h
3. Component Cesspool(s) El Septic Tank El right an Gre�ase Trap
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ther(describe):
4. fluit Tee Filter rNnt If yes, was it cleaned?
5. Observed condition of component pumped:
_ ms.
6. Sys raped y:
Name VehicleLicense Number
St w rt's Sep tic 58 S . Kimball St.,, radfbrd,MA
Company
". Location where contents were disposed:
Is . I jut Bra 'ford A
—Z- . .m.m . ..w . .mm . .w..m w.._--
S nature of Hauler Date
S ig
ignature of Receiving Facilityattach facility receipt) Date
t form .d * 11/12, System urn n Record#Page 1 of 1
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