HomeMy WebLinkAboutGrease Trap - Sludge - Septic Pumping Slip - 351 WILLOW STREET 7/8/2019 Commonwealth of Massachusetts
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System PumpingRecord
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DEP has provided this form for use by loical Boards of Health. Other forms may a use , but the
information must be substantially the same as that provided here. Before using this form, check with your
Ilocal Board of Health to determine the form they use. The System Pumping Record rust be su mitt mitted t
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the local Board of Healthr other,approving authority within 14 days from the pumping date In
accordance with 310 CMR 15.35
A. FacilityInformation
Important:When
filling out forms 1. Systern Location:
n the computer,
use rnl the tad
key to move your Address
cursor-do not No. Andover MA
use the return ......,, .,.
City/Town State Zip Code
2. System Owner:
Name
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Address cif different from,location)
..........
rvm.�.,m„.. ..
City own Stag Zip Code
Telephone Number
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B. Pumping Record
11. Date of PumpingDate 2� a ntlt� Pun Gallons
I Component: El C ss 1 s, El Se tic' 'an 'i 1 t '' nl reasTrap
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El Other(describe):
, Effluent Tee Filter present EJ, Yes n No If yes, was i't cleaned? Yes No
51., Observed n� itln of component pumped-
6. System Pumped By:
Name VehicleLicense Number
Stewart s Sel
ptic 58 So. Kimball St., Bradford,MA
Company
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T Location where,contents were disposed:
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20 So. Milli St., Bradford, M
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Signature tur of Hauler late
Signature of Receiving Facility(or attach facility recent) Cate
t f rrn,4. *11 System Pumping Record r Page I of 1