HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 351 WILLOW STREET 7/8/2019 * � MassachusettsR,
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Commonwealth of ,,,�/i�a�
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City/Town No. Andover
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EP has provided this fora use by local Boards of Health, Other talus may be used, but the
information it ust,he substantially the same as,that provided here. Before using this form, check with your
loll 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 its
accordance with 3110 C R 15.351,
A. Facility Information
I r rt nte1,Wham!
filling out forms 1. Stem Location:
on the computer,
use only the tad
.m.. mm ..,....
key t ►move your Address
cursor not Andover MA 01845,
use the return
City/Town State Zip Code
t
N System Owner.
-..-
ab
Name
Address if different from,Il a ion
Cit `+ wn State Zip Code
Telephone Number
B. Pumping R,ecord
1. Date of Pumping IDate �2. Quantity ''mp e Gallon
i
31. Component" El Cess I s Septic Tank right Tank Grease Trap
E] Other (describe):
4
. Effluent T" i�lt r present? El Yes if yes, was it cleaned? Yes Ej l
5. Observed condition;of component pumped:
6. System Pumped By:
a Vehicle License Number
t art� tip 5 So. Kimball St.,, Bradford MA
� .' _ rr. _._ _ �.., .m.. m., .w mm mm. . �� .m_ ..,
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
Signature of Hauler r Date,
Signature l:Receiving Facility r attach facility
receipt) at,
t5fc rm . oc* 11/12 System,Purnping Record Page 1 of 1