HomeMy WebLinkAbout- Septic Pumping Slip - 85 COLONIAL AVENUE 6/17/2019 �ri, 1�IrrirUs ns;ilK IV
Commonwealth of Massachusetts
City/Town
US ETT-113A)]1\1
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System Pumping Record
Firm
DEP hasprovided this form,for use by local Boards,of Health. The System Pumpling Record'must 1
e submitted to the local Board of Health or other approving authority.
A, Facility Information
When filing out 1 System Location:
forms the
computer,idea co
only the tab key Address
to move your Nosh Andover MA 01845
cursor-do not
C11ty/Town State Zip Code 1
use the r t m
2. SystemOwner".
rf mAddress(if different from location)
a
d
City/Tom State Zip Code
C?-7 ,5—Ocl
Telephone Number
BX Pumping
Z,
1. Date of Pumping 2. Quantity
DateGallons
3 Type of system, C ss o s) zol�septic Tank El M t dank
0 Other(describe):
_ l
" 1
. Effluent Tee Filter present? Yes ET No If yes,was it cleaned? Yes No
5. Condition of System*
wag P:--
6. System Pumped � .
Name Vehicle!License Number
Wind River Environmental
Companyn a 9
7'. Location where contents were disposed. MAO
rt
Sig itur of Hauler' Date
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