HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 239 GRANVILLE LANE 7/8/2019 ,; �;�'°✓ I oa o�d,Jj;�i9 pv/l11`&'U%r ,,�
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Commonwealth of Massachusetts
ity/Town of No., Andover
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4 System Pumping Record
U A N("Ili ly ill I�IV;,` s f,,,,,�N Y.����
Form 4,
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E has provided this form four use by local Boards of Health. Other forms may be used, but the
information rust be substantially the same as that provided bare. Before using this fora, check with your
local Board of'Health to determine the fora they use. The System mpin Record rust be,submitted to
the local Board of Health or other approving authority,with,in 14,days from the pumping, date in,
A. Fac"Ifilty Information �
Important.:When
filling out forms 1 System Location*
on the co t �r 1" 5, �, ,,
use only h w � � ' t' '°U
key to mioveyour Address
cursor do riot, 1 . Andover ov r A
use the return ....��... �rym,�. „.... ..........
key, ��'1""Cit w, r State Zip Code
2 Syst+ r Owner:
Name
Address, if different from location)
City wry State Zip Code
Telephone Ner r
B. Pumpling Record
1. Date of Pumping i2. � 'tit Pued.
Cate re �allons
3w Component* Cess 1 s) Evs,"',epticTank El Tight,Tank El Grease'Trap
E] Other (describe) w mm. .....
W Effluent i
fl� rrt �� Filter �r � r�ty ° �.� � if � � � it l��l� �
5. Observed condition ofcomponent umped
I
6. ;cyst Pumped
N me Vehicle License
Number
Stewart s Septic 58 S . Kim ball St., Bradford�l
Company
7. Location where contents were disposed*
So. Mill St., Pradford, MA
Sig t re o f gull r Date,
-......,u,- . .,. mmrvmm. ...w �-�.. �,.�_ . .. .. .....�.
Signaturef I lw�+in a cility(or att hfacility receipt) Date
t f rr .d #I 1/1,2 System Purnping Record Page I of