HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 6/10/2019 (5) k o It o Massachusetts
City/Town of No. Andover
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Systern, Pumping Record
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DEP has provided this fry use local Boards I�eN ' , Other forms aye used, but
information must be substantially tha same as that provided here. Before using this f rn check with your
local Board of Health to,determine the ford they use. The System Pumping Record rust be, submitted to
the local Board of Health or other approving, authority within 14 days from the pumping date in
accordance with 310 CAR 15.351!.
A. Facility Information
Important:When
fulling out forms 1. System Location,
on the computer,
use onlythe tab VVI ('(6 0
mrrnr.ine ..,inm rmwmm uv��uu�—.. .,-mmr �mmmn rmurmmormm nn n im.n.i
key to move your Address
cursor not 1 . Andover MA 01845
use the return
I City/Town State Zip Code
2. System O rs+ r�
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s
Name
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Address if different from Trom location)
City/Town State Zi Code,
Telephone Number
B.
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1. Date f PumpingDate 2. QuantityPumped: � hl ,
3. Component: C ss 1 s, ` ti ` Tight Teak Grease Trap
El, Other(describe),*
. Effluent Tee Filter present? El Yes No If yes,, was it cleaned? Yes 0, No
5. Observed condition ofcomponent pumped:
6. Sy 6 Pumped w
Vehicle License Number
S eve r's ptic,'58 So. Kimball St,., Bradford,MA
'. Loc i �n w contents were disposed:
2 S . bill St. Bradford, MA
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-iu4,ref H—a-ul,eir Date
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Signature of Receiving, acilit (gar attach facility receipt) late
t5f rr . ' * 11/12 System Pumping Bedard Page 1 of 1