HomeMy WebLinkAbout- Septic Pumping Slip - 21 SOUTH CROSS ROAD 6/10/2019 uommonwealth 1 Massachusetts
«,o ECEIVED
I
�
City/Town of No. And
I, IJ
System Pumping Record
,W Form d °yy'"44 I� ANDWEER
E Nj"
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
iota and Health t determine ine the fora they use. The System inn Record must submitted t
i I M M i, J
the local Board Health rother approving authority within days from the pumping date
accordance with 310 CMR 15.351.
A. Facility Information
Impoft nt When
filling out rr s M SystemLocation.-
on
try .
use only the tab j
key to move your Addresscursor-dio not I
No. Andover M 5
use the return
.m , _. _rvrv,, ... .., .... .,.
City/Town ;Mate Zip Code
w
2. Systlern,Owner:
tab
V
Name,
differentAddress(if from location,)
City/Town State Zip Code
Telephone Number
B. Pumping Record
J
's, 0
11,1 S 0-0
1. Date of Pumping Pumped.
Da t M Quantity Gallons,
3. Component: El, Cesspool(s) tii Tank Fight Tank 0 Grease Trap
E] Other(describe): mmmm. , .m....,. ... ...,,. ... _.... „m,
M Effluent Tee Filter present?, ! Ye No If s, was it cleaned? Ej Yes N
l
. Observed condition of comps ent pum dA/i
d
6.
r
4
�y,�stern--Pumped
m
µl u
Name Vehicle License Number
r
� w i t i �, Bradford,.tom' rt .n m �,a _ . mm. . „ ,m.w.
Company
7. Location where contents were disposed®
20 So. Millw Bradford,, MA
m
inatre t air Data,
i
Signature receiving Facility r attach facility receipt) Data
t f rm .do w System ur pia record Page+ 1