HomeMy WebLinkAbout- Septic Pumping Slip - 73 RIVERVIEW STREET 6/10/2019 Commonwealth of Massachusetts
City/Tolwn of .No, Andover
............
System Pumping Record
................ rA`OF 1f111'11'1'(
Form 4
DEP has provided this form for use by local Boards of Hea.1t . 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 approving authority within 14,days from the pumping date in
accordance with 31'01 CAR 15.351,
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tad
key to move YOUr Address,
cursor-do not No. Andover, MA 0,18,45
use the return
.key C,ity/T'own State Zip Code
Ah 2. System Owner:
VGA
t........ 11.1W S
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
R. Pumplong Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: El Cesspool(s) "ep tic'dank El Tight Tank El Greasy trap
El Other(describe):
4., Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No,
5. Observed condition of component pumped:
6. System Pumped By,
Name Vehicle License Number
e Bradford S fi ,MA
Company
7'. Location, where contents were disposed:
20 So. Mill St.,, Bradford, MA
Signature of Hauler Date
.............. ......
Slignature of r iving,Facility(or attach facility receipt) Date
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