HomeMy WebLinkAbout- Septic Pumping Slip - 373 RALEIGH TAVERN LANE 7/8/2019 Commonwealth of Massachusetts
RECEIVED
ZT— T ver
System Pumping Record
Form �4
TOWN 0F'N(.,',R%T11,-,1 ANDOVER
/U-��IINE JNT
xy
DEP has provided this form 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 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 310 CIVIR 15.351.
A. Facility Information
Important: when
filling out forms t System Location:
on the computer,
use only the tab
6-01
key to move Your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
v[6 V fe,o
Name
Address(if different from location)
City/Town State Zip Code,
Telephone Number
B. Pumping Record
1 Date of Pumping 2. Quantity Pumped:
Date allons,
3. Component: E] Cesspool(s) 0`0 Septic Tank EJ Tight Tank El' Grease Trap
Other (describe):
4. Effluent Tee Filter present? E] Yes 0 No If yes, was it cleaned Yes No
5. Observed condition of component pumped:
C)Ci
6. SysteqP ed By:
..............
Name Vehicle License Number
Stewart's Sep�lc 58 S'o. Kimball St., BradfordIVIA
Company.
7. Location where contents,were disposed:
� adford, MA
20 So. Mill
i6ture, Hap,' Date
Signature of Receiving Facility(or attach facility receipt) Date
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