HomeMy WebLinkAbout- Septic Pumping Slip - 61 ABBOTT STREET 6/10/2019 I
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Massachusetts
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City/Town of No. Andover
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System! Pumping c
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Form 4 «a
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DEP has provided this fora for use by local Boards of Health. Other forms may be used, but the
information must be,substantially the same as that provided here. Before using thisform,, check with your
local Board of Health t determine ine the form they use. The System Pumping Record must be submitted itt t
the local Board of Health or other approving authority within 14, days from,the pumping date i
accordance with 310 C R 15.351.
A. Facility
Important:When
filling out forms 1. System Location-
on the computer,
use only the tab
key to move your Address
err-do not
use the return
City/Town State Zip Code
2. System Owner:VQ
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Name
1
Address if different from l l ti n
City/Tr State Zip Code
'Telephone Number
B. Pumpling
1. Date
i f W
Quantity Pumped:
Cate Gallo '
3. Component: Cesspool(s) El Septic Teak Tight Tank Grease Trap
El Offer(describe):
. Effluent Tee Filter resents El Yes Ifyes, was it cleaned? I
5. Observed condition n component pumped,
... u...
ry
6. System Pumped
17
o,Im .,,
Name Vehicle License Number
Stwart"s S i..c 5 S . Kimball St., rr A
� t �. � ._
Company
. Location where contents were disposed
20 So. Mill St., Bradford, M
Signature of Hauler Irate
Signature of Receiving Facility( r attach facility receipt) Date
t f rrn - # 11/12 System Purpling Record*Page 1 of 1