HomeMy WebLinkAbout- Septic Pumping Slip - 1148 OSGOOD STREET 7/8/2019 Commonwealth of Massachusetts
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6 C ity/T I EGMI ED
own of No. Anidover,
System Pumping Record
Form 4
VEl"Z,
DEP
ike�16 ay be used, but the has providedthis form for use by local Boards of HeAi�ih
information rnust be substantially the same as that provided here,. Before using this form, check ith youir
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 CMR 15.351
A. Facility Information
Important:When 1. Sytem Location'.filling out forms s
on the computer,
use only the tab
key to move Your A ress
cursor-do not
„m�mmNo. Andover MA 01845
use the return
key. City/T'own State Zip Gode
2. System,Owner-
5,
Name
few
Address(if different from location)
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City/Town State Zip Code, "
Telephone Number
B. Pumping Record
2. Quantity Pumped.-
Date Gallons
3. Component: El Cesspool(s) 9Septic Tank, 0 Tight'Tank El Grease Trap
Other (describe):
4. Effluent Tee Filter present? El Yes ff No If yes, was it cleaned Yes No
5. Observed condition of component pumped:
6. Sys em Pumped, By:
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Nave Vehicle License Number
Stewart's Septic 58, So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. 111 Bradford, MA
Date 2'
i nature Oauler ,
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Signature,of Receiving Facility(or attach facility r ipt) Date
t5form4.d'oc,11/12
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