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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