HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 135 CANDLESTICK ROAD 7/17/2019 RECEIVED
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i
Of Massachusetts
C1ty/T0Wn of
ev
system P
UMPIng Record
tjogjAA ANDOVE-R
Form 4
) WE ,
i
DEP has ProWded this for
InformationOcal Boards Must , � �substantially� Health� Other �
focal, that i � � but the 1
of Health ,determine the forthe local 1300rd of Health or bther approving out Before s bls f
System Pumping Record must be submItted to
cC o with 310 CMR 15.3sl. horltthin 14 days from the pumping date In
As Facility, I
Mn,When
MIN,Out forms I it ;system Location:
on the computer,
use only the tab, It , T�
key to move your r
cursor- not
Use
key —ltyow
� �rr
1
Ste 0
OM Owner# ZIP C
Name
TAddress( � from
fit ,
stag
B. Pu
Telephone Number
pinRecord
".1
Date of Pumping
Date 2, Quantity Pumped:
3. COmponent; C'988P001(s) Septic,Tank Gallons
EJ Tlght Tank Grease Trap
Other(describe),
t
4* Effluent Tee Filter Present? C] No
t
If y8s, w8S Iteleaned? Cj ye
6 Observed condition,Of component
- System Pumped By:
Name
Vehicle
Service l &Drai o i Anse Number
company nrxrt
t
North-Readin&MA 0 18,64
where7'* Location w � s ,
ik,
Owl
tee,
,w
receipt)(or foQ1111y
Date
t6torm4.doo*11112
System Pumping Record,@ page 1 of 1