HomeMy WebLinkAbout- Septic Pumping Slip - 16 CARLTON LANE 6/10/2019 �ro
Commonwealth of Massachusetts Jf� 1!,�"
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City/Town of' No. Andover
System Pump"IrIlg Record
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DEP has provided this,form for use by local Boards f Health. Other forms may eI used,, but the
j information must be substantially the seas as that provided 'here. Before using this fora, check with rM
local Board of l ealth determine inn the fora they use. The System Pumping Record must be ,submitted to,
the local Board of Health or other approving authority within 14 days from the pumping date in
A. Facility Informati'on
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Import rr ip.,When
filling out forms 1. Systern Location:
on-the computer,
use only the tab
key to move your Address
cursor-do not No. Andover MA 0`1845
use the return ""... "..."""""
City/Town State dip Code
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. ,system;,Owner-.
tab
,�,,,,, , ..,,,Name
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Address if different from location)
it [T wn State Zip Code.
NumberTelephone
B. Pumping Record
Date of Pumping 2. Quantity Pumped'. 11..mm.�.m.
1t Gallons
3. Component: El Cesspool(s) MSeptic Tank T'iight Tangy Grease Trap
Other(describe) ""... "..
. Effluent Tee Filter present? Yes,, was it cleaned? Yes 0 No
5. Observed condition of component pi p :
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. System Pumped By:
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m Licenseurn i r
St wart's Septic 58 Sow Kimball St., Bradford,MA
Company
. Location where convents were disposed:
20 So. Fill St. Bradford, MA,
Signature of Receiving Facility r attach facility receipt) late
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