HomeMy WebLinkAbout- Septic Pumping Slip - 104 BRIDGES LANE 7/8/2019 Commonwealth
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........... System Pumping Record
Form
DEP has provided this foam for use by local Boards of Health. Other
"""iorms-1)m"a"y be, used, but the
information must be substantially the same as that rovided here. Before using this form, check with your
local Board of Health to determine the form they use, The System Pumping Record rust be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
i
accordance with 310 C 15.351.
,A, Facifity Information
Important, When
filling out forms 1. System Location;
on,the computer,
use only the tab
key to move your Address
cursor not . Andover M 5
use thereturn
,.„ mm� p
1 City/Town State Zlip Code
2, System Owner:
Name
Address if different,from location)
Clt T n Stag Zip Code
Telephone Number
B. Pumping
(6,
µ 5
1 bate f Pumping 2. Quantity Pumped:
Date el, Gadons
3. Component: El Cess 1(s) Septic Tank Tight Tank, Grease Trap
El Other(describe),*
., Effluent Tee Filter r sent Yes , l If yes, was it cleaned El Yes N
5. Observed condition of compgpent pumped:
6. SstPumped
n � 00
Name Vehicle License,Number
Stewart' S tic 58 So. Kimball St, r df r........... A
Company
. Location where contents were disposed;
t
20
Sp MillA,
B rd rd, MA _
Wd
100
lop
SignatUre of Hauler Date
'
1
Signature of Receiving�Facility(or attach facility receipt) Date
1
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