HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 TANGLEWOOD LANE 7/8/2019 Commonwealth of Massachusetts
System Pumpi'ngl Record
City/Town of No. Andover
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DEP has provided is form for use by local Boards of used, but the
information must be substantially the same as that provided here. Before using this forma check.with "' 'r
local Board of Health to,determine the fora they use. The System Pumping Record must be submitted t
the local f e nth or gather approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351
A, Facility
Important:When
filling out forms 1., System Location:
n the computer,
use nly the tab . �mm
key to move your Address
cursor- not N . Andover 01845,
use the return mm. ..
CitylTown State Zip Code
2. System`~ Owner:
Name
Address if different from location)
City/Torn State Zip Code
Telephone Number
B.,
Pumping, Record
1. Date of Pumping2. Quantity Pumped: Gallons
3. Component: Cesspool(s) ElSeptic Teak El Tight Tank El Grease,Trap
i
El
Other describe):
i
. !Effluent Tee Filter present? Yes No, If Y st was it cleared? Yes
5. Observed condition of component pumped:
. System By
® _�
Name Vehicle License Number
u� tic 58 So., Kimball St., BradfordM
Company
7. Location where contents were disposed
20 So., Mill St., Bradford,, MA
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j " f er Date
,
Signature f Receiving Facility iIlt r attach facility receipt) Date
t5f+ rm .d s 11/12 System Pumping Rec rd#Page 11 f"I