HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 7/8/2019 uommonwealthl olf Massachusetts
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City/Town olf' No. Andover
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System Pumping Record
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'Form � ;d
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DEP has provided this form for use by local Boards,of Health., Other forms may be used, but the
information rust be substantially the same as that provided here., Before using this form, check with your
local'' r Health to,determine the form they use. The System Pumping Record' must be submitted t
the local Board of Health or other approving authority within 14 da 's from the pumping date in
acco rda gin ,with 310 CM R 15.35 .
X Facility Information
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Important:When
fill'ing olut forms M System Location:
on the computer,
use only the tab "135
key 1
to moveJ-!9
cursor-do not l " A�� �r
use the return
MA
key" Mate Zip Code
2. System Owner:
Name
Address(it different from l ration)
City/Town State Zip Cody
Telephone Number
B. Pumping
1. Date of Pumping
..
d,
, t Gallons
31. Component,- Cesspool(s) R'Oe�Septic Tank 0 Tight Tank El Grease Trap
Other(describe):
. Effluent Tee Filter resent? Ej Yesfff"ONo lf'yesi,, was it cleaned? El Yes [:] No
5 Observed nithn of component pumped,,
6. System Pumped' By-
1110
Name! Vehicle rrr l ' r r
Company
7. Location where contents were disposed:
Bradford,
4J
Signature ofHauler Date
.. �.m.. m..... m. mm....
Signature Receiving Facility r attach fac ility receipt)
trrrr 'N' System Pumping Record Page I of 1'