HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 SPRING HILL ROAD 7/8/2019 A
Commonwealth of Massach"Usetts
City/Town of No.. AndoverSystem Pumping Record OF
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has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Hea,lth to dietermine the fora they use. The System Pumping Record must be submitted
the local Board f Health or other approving authority within 14 days from the pumpling date in
accordance with 310 C M R 15I351.
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filling out forms 1 System Location:
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use only the tad
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cursor-do,not No. Andover MA
use the return
key. City/Town State Zip Code
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Owner-
Name
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B,, Pumpmin,g Record
1. Date of Pumping ua tit Pumped* 00
Cate Gallons
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3. Component: Cess i s, Septic Tank El Tight Tank 0 Grease Trap
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El Other (describe)*,
Efflulent'Tee Filter presents 0 Yes, ROOONo If Yes,, was it dale 0 Yes D No
5. Observed c i ti n of r n t�,pumped:
6. System Pumped By:
Name Vehicle i l License Number
Stewart's ,Septic 58 So. Kimball St.,, Bradford,,MA
Company
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T Location where contents were disposed.
29 ill St, Br ord MA
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Signature of'Hauler Date
;Signature of Receiving Facility r attac,h,facility receipt) Date,
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