HomeMy WebLinkAboutEQ Tank - Septic Pumping Slip - 351 WILLOW STREET 7/8/2019 uommonwealth Massachusetts
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ZI C"ty/Town f No. Andover
System Pumping Record
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DEP has pr idedthis form for use by local Boards of Health. Other frets may he used, but the
information must be, substantially the same as that provided here. Before using this fora, check with your
local Board of health to determine the fora they use. The System, Pumping Record must be, submitted
the local Board of Healthr other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor not 1 . Andover 5
use th r tur _ ,� -. ,....., .. �m. ._.m,n .. .rv...., .mm�.
pity Town State Zip Code
2. System Ownerm
Name
Address if different.from location)
City/Town State Zip Code
Telephone Number
Bli,, Pumping Record
1. Date of Pumping , . .�... .��:.�,�� � . Quantity P r ' �
�.„ ......�
Date Gallons
3. Component: Cesspool(s) El Septic Tank Tight Tank El Grease Trap
Other(describe): . . .. mm� . . mr. W .......
. Effluent Tee Filter present? 0 Yes E' No If'yes, was it cleaned"? Yes No,
5. Observed condition ofcomponentpumped:
6. System Pumped y
f
Name
1
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VehicleLicense Number
Stewart's Septic 58 So. Kimball St., Biradford,,MA
Company
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w Location where contents were disposed.
20 So. ford,
MA
Signature of Hauler Date
Signature of Receiving Facility r attach facility receipt) Date
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