HomeMy WebLinkAbout- Septic Pumping Slip - 514 WINTER STREET 6/10/2019 °
r f
N
All
luommonwealth of Massachusetts
r,, f
Uity/Town of No. n ve
. I M
GI I System Pum' ping Record
Form
DEP u
has provided this form,for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same a,s that provided here. Before using is forma, check with your
local Board of Health to determine the forma they use. The System Pumping Record must be submitted t r
the local Board of Health or other approving authority within 14 days from the pumping date i
accordance with 310 CMR 151.351.
AN, fi
FacollityInformation
Important:When
filling out forms 1. System Location
on the m ut r,
use only the ta,
key,to move your Address
cursor rsu r-do not . Andover MA 018,45
use the return .w,�., .. ,,,�« rv. �.rvm..mm,m,ry. �...
1 ZipCode
2. System Owner:
Name
Address if different from location,)
City row State Zip Code
tj
Telephone Number
B. P u m pi,
5-e'. 6
1 Date f u u �,mm .��.m.�.�. ���._��.,. �,,,, Quantity um e ,
Date Gallons
3, Component: Cesspool(s) elleptic Tank, Tight,Teak Grease Trap
El Otlh r (describe) ..m�..ro,.w. .. ....., �. .. .. .,,, u.
., Ef�flu ent Tee Filter,present?ff- ,,Yes � N if yes, was it l n Yes No
5. Observed condition of component plumped:
M vuww�
e4,t/v <s7 A/dr,
um
IJ.
. Sst
.,,. .. . .. .m.2...
Name Vehicle License 'u r
Ste rt's S ic 58 So. ball St, Bradford,IVIA
Company
7. L cation where contents were disposed:
So. Mill St. ra r'd MA
r
Si nature f hauler VDate 621_
gnature of Receiving Facility r attach facility receipt) Daf
it
t form o 1 /12, System Pumping Record Page 1 o f I