HomeMy WebLinkAbout- Septic Pumping Slip - 26 LONG PASTURE ROAD 6/10/2019 h of
Commonweait
. Massachusetts
City/Towrl of No. Andover
System Pumping Record
Form
1
P has provided this irm for use by local Boards of Health. Other forms may be used, but the
information rust be substantially the same s that provided here., Before using t !'�1s form, check with your
local Board of Health to determinethe fora they � s . The, System ' rnping Record must be, submitted wittu to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310, C R 115351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on,the computer,
use only the tab
key to rnove your Address
cursor-d not l" . .ndove 5
use the returnCity/Town ,,,,,., G„�„�.�..,.. State
..., . . ..,. .m,.,.m,..
2. System Owner:
tab
tk�, V
Name
Address of different from location)
City/Town. .. m, .. n„ .. , ,.mm,. m.,n,,,ry . ,,,.r...m �., ... . �.._ S
date Zip Code
Telephone Number
B. Pumping
,0,
1. Date of Pumping Date 2. Quantity Pumped:
t
3. Component: El Cesspool(s) [3- Se tic Tank 0 T 'Tank Grease Trap
i
Other(describe):
. Effluent,Tie Filter present?.sent" Yes [!<No If yes, was it cleaned? Yes El N
5. Observed conditon ofcomponent ter :
0,0
. Systems Pumped By:
Name Vehicle License Number,
S w rwt"s S tic..58 So.µKimball St., Bradford,MA
Company
. Location where contents were disposed:
2 S . Mill St. Ir d r , MA
51,7
r A 01 ler late
Signature of Receiving flit ' r attach facility receipt) Date
t f rr .d w 11/12 System Pumping and Page I of I