HomeMy WebLinkAbout- Septic Pumping Slip - 58 EVERGREEN DRIVE 6/10/2019 u m o e h of M assachusetts
��1
City/Town, of No. Andover
=:=7Z
System Pumping Record
IM,
j i'v'i
DEP has provided this form for use by loca,l Boiards:of Health, Other forms may be, used, but the
information must be substantially the same as that provided here. Before 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 appiroving authority within 14 days from the pumping date, in
accordance with, 3,10 CMR 15.351'.
A. fi ion
Important:When
fiffing out forms 1. System Location:
,on the computer,
L
use only t i
he tab ......
key to move your Address
cuirsor-do not No�. And over MA 018,45
usethe return
key. City/Town State Zip Code
2. System Owner.-
tab
Name
Run
Address if different from location)
City/Town State, Zip Code
IM Telephone,Number
B., Pumping Record
it 1 Rui 1 of'Pumpi t,
i eel
-nped:. Date lng an 2. Quti
Date Gallons
3. Component: cesspool(s) Septic'Tank E:1 'Tight Tank [:1 G:aase Trap
Other(describe)-.
4. Effluent Tee Filter present? Yes If yes, was it cleaned? Yes No
5. Observed condition of component purnped:
�q
�j
6. System Pumped B%/:
Name 'Vehicle License Number
58, So. Kimball St., BradfordMA
Company
7. Location where, contents were disposed:
20 So. Mill St,, Br ford, MA
31 i e it Date
........... .................
Signature of Receiving Facility(or attach facility receipt) Date
t5f,orm4.doce 11/12 System Purnping Record Page I of 1