HomeMy WebLinkAboutGrease Trap - Heavy Sludge - Septic Pumping Slip - 351 WILLOW STREET 7/8/2019 o//
Massachusetts
Commonwealth f
Glity/Town of No. Andolver
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System
Pumplong Reco "i,��'P,rl,�yeµ
�N l;,w av My"^l
Form
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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 Board of Health to determinethe form they use. The System mpin Record must be submitted itte t
the local] Board of Healthr other approving authority within 14 days 'r m the pumping date in
accordance with 310 CMR 15.351,
A. Facility Information
Impor,tant:When
filling out forms 1. System Location*
on the computer, ry ,
use only the tab
key to move your ,Address
ar-do not N . Andover M
use the return ... ,,,r .. ._ ... mrv.�..,..�..
key., City/Town State Zip Code
i
System Owner:
(A-tik,
Name
Address(if different from,location)
Clt /Town State Zip Cod
.�.....
Telephone Number
B. Plumpillng Record
0
µ
. Cate of Pumping 2, Quantity Pumped:
Date Gallons,
3. C orrery . Cess I I s Septic Tank Ej Tight Tank Bo'laase Trap
Ej Other(describe),
4. Effluent Tee Filter present? Yes Ej No It yes, was it cI Yes I
5. Observed condition of component pumped:
6. System Pumped By: top
Name Vehicle License lumb r
nStewart's Se�w tic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed'.
20 So. Mill St., Bradford, M
Signature of Hauler Date
Signature of Receiving Facility or attach facility receipt) Irate
t for l, l o 11 1 System Plumping Record Page 1 of 1