HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 6/10/2019 (3) RECEI'VED
m o� th. oss cht ,r%�»u�i/elJrliN City/'Town of Now, Andover
System Pump"Ing Record
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Form 4
DEP has provided this fora for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that,provided here, Before using this form, check with your
Vocal Board of Health to determine in the fora they use. The,System Pumping Record rust be submitted to
the local Board of Health or other,approving authority within ddays r m the pumping date in
accordance with 310 CM R 15.351.
A. Facility Information
Irrti When
filling out forms 1. System + ati w
on the computeir, W1 6,VV
use only the tab
Ivey to rove your Address
rsr N . AndoverMIAuse the return fit rw S m�.. Zip Code,
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key,
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2. System Owner:
/V
00 Name
P
Offn
Address different from location)
City/Town State Zip Code
Telephone Number
9..
B. Pumping Record
1. data of Pumping Date �,..m..�W.... . mm 2. Quantity, Pum le : Gallons
3. Component: Cesspool(s) .Septic Tank 0 Tight Tank El Grease,Trap
El
r
Other We scribe).
M
i
resent. desUeN""oIf
4. l��elr�t Tee 'iItr� s, was it cleaned? El Yes No
5. Observed condition of Campo ent ran
6. System Punped
col
Name "vehicle License Number
SItewart's Septj��,,58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed-,
20 So. ill St. Bradford,, M
Signature of Healer Date
i
Signature of Receiving Facility r attach facility receipt) Gets
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