HomeMy WebLinkAbout- Septic Pumping Slip - 274 FOSTER STREET 6/10/2019 1'
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' RECEIVED
Commonwedfth Massachusetts
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City/Town, of No., Andover
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Sympling
stem Pu Record
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Hll IHEM.
E has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially e same as that provided here. Beforeusing this form, check with r
1l ca1 Board of Healthto det�ermin�e the fora they use, The System Pumping Record must be submitted
the local Board'of Health or other approving authority within days from the pumping date in
X, Facility
Important:When
filling out forms 1 y System Location:
ril the computer,
use only the tab
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mm . ..
key to move your Address
cursor-do not No. Andover MA 01 1845
use the return City/Town State Zip Code
2. SystemOwner:
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Nam �
Address if'different from location)
It /Town State Zip Code
Telephone lint r
B,, Pumping Record
I. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component-, Cesspool(s) Septic Tart Tight Tank Eli Greasel Trip
El Offer(describe): ......
Effluent Tee Filterpresent?, 'es No If yes, was, it cleaned? Yes No
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5. Observed condition of component pumped:
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1'rrie Vehicle brae Number
StewardSeptic 58 So. Kimball St, Bradford,MA
Company
7. Location whiles contents were disposed:
2 S Mil' . ra f r
_ — mm�.�,.. _
h
ture of'Hauler late
Signature of Receiving Facility( r attach facility receipt) Date
t5f rrnil..d cs *1 12 System Purnping Record mega I of I