HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 7/8/2019 v�w�vi�li�Ys�i �avurr ��nan�iv� � r o
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uil�omm,onlwealth of Massachusetts
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City/Town o No. Andover
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TOWN
System Pumping Record
LT 11
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Form i
DEP has provided this fora for use by local Boards t'Healt . Other forms may be used, but the
information must be substantially the same as that,provided here. Before using this fora, check with your
local a1 Board of Health to determinethe form they use. The System Pumping Record rest be submitted
the loyal Board of Health or other approving authoritywithin 14 days from the pumping date in
accordancewith 310 CMR 5.35 .
Facility
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab (I em
........... .........
key to,move YOUr Address,
cursor.. rapt l o., Andover M 11 8 5
use thereturn �...�m � .
City/Town State Zip Code
1
2. System Owner:
VQ 1
Le- 1
Namet
f
f
x yyyjy�1g f
r
Address(if different from location)
City/Town State, Zip
C
e
Telephone Number
B,, Pumping Record
1. Date of Pumping r .�..�.��.� �. trait Pumped:
: � �_..___''�. Gallons
3. C r p ent: El Cesspool(s) Septic Tank 0 Tight Tank Ej Grease r ,
Other(describe):
. EffluentTee Filter present? El Yes El No If yes, was itcleaned? Yes No
5. Observed condition of component pumped:
6. System Pumped :
Name Vehicle,License Number
Stewart's Septic 518 So. Kimball St. Bradford,MA
Company _®
i
. Location where contents were disposed:
20 . Dill St., Bradford, MA
�i�rtr�
Ntiler Date
.�..,M._._�_., ...
Signature of Receiving Facility or attach facility receipt) Date
t5 rm .d * 1,1112 System Purnping Record lugs I