HomeMy WebLinkAbout- Septic Pumping Slip - 3 ELLIS STREET 6/10/2019 ���
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Commonwealth of Massachusetts
City/T'own of No. AndoverZ;"_711, 7-17-11"
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Form 4
C EP has provided this fora for use by local 1 Boards ofHealth. Other forms may be used, but,the
information rest be substantially the same as that provided bare. Before, using this fora, chec,k,with your
local ar Health to determine the form they use. The System Pumping Record must be submitted t
the local Board of Healthr other approving authority within 14 days fromi the, purriping date in
accordance with 310 CMR15.351.
,A. FacilityIre a on 1
1
Important:When
filling a forms
. System Location.*
on the r m ut
key to move your Address
cursor,use the- notreturn, . Andover ,�1
City/Town State Zip Code
2. SystemOwner:
tab
s
Name
Address,(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping
. Date,of P u m i n ', 2. Q rtt i ty m �.m., �,�,:���..mmm��.....�� ������ .���....� .
It Gal ons
3. Component: El Cesspool(s) YSeptic Tank Tight en Grease Troup
El Other (describe): w... .. . ................
w Effluent Tee Filter,present?, Yes No If yes, was it glen ' Yes No
5. Observed condition fcomponent pumped:
t
i
. S em bumps B :
J
Name Vehicle License Number
hurt�Septic 5 So. Kimball, t., ral r ,l
�n
Company
`'. Location where contents were dispose:
20 So. 1",.ill ,fit., Bradford, MA
.........n t �r Lfl r Cate
Signature of Receiving Facility(or attach facility receipt) Date
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