HomeMy WebLinkAbout- Septic Pumping Slip - 17 WILDWOOD CIRCLE 7/8/2019 fKVsip ""'
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Comm,orlwealth of Massachusetts
Uity/Town of No. Andover
OVER
System Pumping Record ANDX,
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Form 4 i
��ion ����
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
informatio�n, must be substantially the same s that provided bare. Before using this fora, check with your
local Board of Health to determine the form they use., The System Pumping Record must be submitted t
the local Board of Health or other approving authority within 14 days from the pumping date i
accordance with, 310 CMR 15.351.
A,, Facility
Important:When
filling out forms 1. System c ti n
on the computer,
use only the tab, �
key to move err Address
cursor-do not N . Andover A 5
use the return �.,,,. �m.,,, �,,�,� nrv�.���- ,ry. .mm.,. �, ,,,..
key.
City/ + rr:. State Zip Code
2. System Owner::
i
few
Address(if different,from l ti �n
City/Town State Zip Code
... .
Telephone Number................
B,. Pumpilng
62,
1. Cate of Pumping 2. Quantity Pumped: ,.,,.� ..,.
5` 0 0
Datell n
3 Corgi nient® El Cesspool(s) Septic dank. fight Tank Grease Trap
Other(describe):
. Effluent Toe Filter present Yes No if yes, was it cleaned? Yes No
. Observed condition of component pumped,
(Jn1
o'
1
6., system Pumped
Name Vehicle L,icensle Number
to Sto� r � ptiom� Kir So. a,l S l t., Brford,M
,. ' .. ,. _. mm...m.
Company
7. Location where contents were disposed:
20 So. l' ll S , Bradford, MA
Signature of 1eiin Facility or attar facility receipt) Date
t5form4.doco 11112 System Pumping Record e I of 1