HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 175 STONECLEAVE ROAD 7/8/2019 µ Commonwealth of Massachusetts
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System Pump"Ing Record
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DEP has provided this fora for use local Boards of Health,. 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 Board of Health,to determinethe fora they use. The System Pumping record must e, submitted t
the local, Board of Health or other approving authority within 14 days from the pumping date in
,A. Facility
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filling out forms System Location:
on the computer,
use only the tad c ��
Ivey to move your Address
cursor-do not No. Andover 01845
use the return m
I City/Town State Zip Code
GA2. System Owner:
"Lip
Name
Addres if different from location)
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City/Town State Zip,Code
Telephone umber
B. Pumping
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1 Date of Pumping Date 2. Quantity, a ,e ..Gallons
I Component: C ss 11 s Septic Tank igh dank Ell Grease Trap
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Other(describe).-
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4. Effluent'Tee Filter presents El Yes, [I No Ifyes, was it cleaned? E] Yes No
5 searcondition f m neat e
6. Syp m Plumped' B
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arms Vehicle License Number
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Stewart's Sep, tic 58 So. Kimball ll St., r f ,
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Company
T., Location where ntents were disposed:
20
110010
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Si n turn f'Hagler mate
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S,ignature of Receiving Facility r attach facility,receipt) Cate
t f rrrr . e 1/ 2 Sy'stern PumpingRecord Page I of I