HomeMy WebLinkAbout- Septic Pumping Slip - 373 SALEM STREET 6/10/2019 Commonwealth of Massachusetts
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Git /Town of No. Andover
Z, System Pumping Record
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Form 4 A,P,10 V E
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has provided this form for use by local Boards of Health. Other forms may ble used, but the
information must be,substantially the,same as that provided here. Blefore using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the purnping date in
accordance with 3,10 CAR 15.351.
A. Facility Infor mation
Impor,tant:When
filling out forms 1. System Location,
ors,tyre
oenclyo tmhe taartebr,
,1 133
key to move your Address
clursor-dio not, No. Andover MA 0 1845
use the return
City/Town State Zip Code
key,
2. System Ownier�
to11 tA
Name
Man
Address(if'different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
S 09
1. Date of Pumping Date 2. Quantity Pumped:
,3. Component: Cesspool(s) arl/septic Ta,nk [j Tight,Tank [:1 Girease Trap
El Other (descrlbe)-
4. Effluent Tee Filter present? El Yes [B/No If yes, was it cleaned? Yes No
5. Observed condition of component pumped',
6. m Pumped By:
1-7 awe Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents,were, disposed:
20 So. j, St adford MA
........................... .......
S1, goreof' aluler Date
Signature of Receiving Facility or attach facility,receipt) Date
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