HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 100 CRICKET LANE 7/8/2019 uomwlonwealth c u
N�J)J/aY 4l U9�//�fUi&;p�A(�Al!lil�fllN rl Iy�f n �'"p"�pp W,ir9FNN�J/1L91 i/�I/i
C'ty/Town
' o No. oeSystem
r
Pumping
Formk),VhJ'1,4
a, 1
D,EP has provided this form for use by local Boards of Healt M ,,If � ��r� used but the
information rust be substantially the same as that provided bare. Before using this form check with your
local Board of Health to,determine the form they use. The System Pumping Record must be submitted to
the local Board ofl-leafth or other approving authority within 14 days from the pumping date i
accordance with 310 CMR 15.351
A,, Facility
Impor,tant.,When
filling out forms 1 ,system Location,:
on the computer,
..........
use l thetali +� � � � �"
key to move YOUr Address
cursor not 1 . State Andover ! 1
use the return City/Town....mm l
� mmm... ,.,.m..,m wm .r � mm.�„ .�w....mmm mm��.�rv�m �.��..�,m .mm m .m�w _. � �....� Zip e
...
key,
2. S stem Owner:
t
1
"I- Nam
1
I
,Addr s if different from location)
mimmmiw�rmrmr.mmmmm.0 �
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped# Gallons
. .. �... �
3. Component: El Cess 1 s Septic Tank Tight Tanya Grease Trap
El Other s ri
4. Effluent Tee Filter reset Yes EJ No if yes, was it cleaned` El Yes 0 No
Observed condition of component pumped:
J
6, System Pumped B
Name 'vehicle License Number
Stewart' Sq tic 5,8 So. Kimball ll St., Bradford,MA
Company
` . Location where contents were disposed:
20 S . fill ,fit., Bradford, MA
Signature of Dealer late
SignatureReceiving Facility r attach facility receipt) Date!
t5form4.doco 11112System Pumping ing Recorde Page I of