HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 6/10/2019 (6) Commonwt-a-alth of Massachusetts
FC" /Tows oAndover
7H7 System Pumpoing Record
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u
Form 4
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DAP has provided this forma for use by local Boards of Health. Other forms may be used, but the
information rust besubstantially the same as that provided here, Before using this form, check with your,
local Board of health to,determinethe form they arse. The System Purnping Record rust be submitted t
the local Board of Health or other-approving authority within 14 days from the pumping date ire
accordance with 310 CMR 15,351.
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A., Facility Information
Important:When
filling out forms 1. System Location
n the computer,
use only the,tab
key to move YOUr Address
cursor-do not
Andover MA 01845
use the return .. ... ......mm.m._..
City/Town State Zip Code
. SystemOwner:
Name
r
Address(if different from location)
City/Torn State Zip Cod. _.
Telephone Nt,irnber
B. Pump:ing Record
1 Date of Pumping � ,�.-�..,,�.mm �,mm,�rv. m�� . a r tl t " r e : �
Date �a1lonsI
I
3. Component- C ss 1 s, El Septic Wank El Tight Tanl Grease Trap
Other(describe):'
i
f
. Effluent TeeFilter present.? No If yes, was, it clam Yes No
5. Observed condition of component pumped.,
6. System Pumped By:
Name Vehicle License Number 1
St art's S tic 518 So. Kimball St, BradfordMA
Company
", Location where contents were disposed-
20
So., Mill St., 'Bradford MA
Si '616ture of Hauler Date
Signature of Receiving ivin ilit r for attach facility receipt) rate
t form . ce 1`/12 System Purnl ing Record Page I ofl