HomeMy WebLinkAboutInterior Grease Traps - Septic Pumping Slip - 351 WILLOW STREET 7/8/2019 fAle M"p/% J"may: flY i�f/if70 nii„
Commonwealth oM Massachusetts
}
J
City/Town No. Andover
System, Puli g Record
[Aly0"o,
UI-
�,r,�
"11,V
Form, 4
J d k f r7
f"r
ff I _'ri
w k I k
DEP has, provided this fora for use by local Boards l 'Health.. Other forms may be used, but the
information must be substantially the same as that provided 'here. Before using th�is fora, check with your
local Board of Health to determine-the form they se�. Th�e System wur inn Record', rust,be submitted ltted t
the local Board of Health or other approving authoritywithin 14 days from, the pumping date in
accord a n ce with 310 C M R 15.351.
A. Facility Information
Imp rt a ate When
filling out forms 1; System Location*
on the computeruse ,
only the tab ..�.�„ w (16 U
..... ,,
key t ,move your Address
cursor not No. Andover M
use thereturn ..., � ...... ....�
key. City/Town State dip Code
tab '. System Owner:
16ii"ZU", 1V 11 -YO
Name
Address(if different from location
City/Town Stag Zip Code
Telephone Number
B. Pumping Record
6 Z
a
1. Date Pumping Datemm.. LL 2. Quantity Pumped".
p d�
Gallons q
3. Component C si l s, tic Tank El Tight Tank El Grease Trap S
E:1 Other(describe):,
Effluent T Filter present? El 'Yes, I 'yes, was It cleaned? Yes
5. Observed condition of component pumped,
6y, sc)
6. Sys,temi Dumped B :
Name Vehicle License Number
r
St w rt's Septic 58 So. Kimball St., Bradford,M .
Company
7. Location where contents,were disposed:
20 S 'Till St., Bradford, MA
Signature natur f Mauler Date
Signature of Receiving Fa i�lit r attach facility receipt) Date
t r r 4.d ce 11/1 System Pumping Record Page I of 1
i