HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 114 PENNI LANE 9/5/2019 Commonwealth of MassachusettsRECEDE
r City/Town of , �1-5 .-;' ; t=P
System ?019
S_
S n � Pumping Record OF ty)RIH ANDOVER
For 'Tom
t)EPARTME�T
DEP has provided this form for use by local Boards of Health. Other forms may be
Information must be substantially the same as that provided here. Before using this for
local Board of Health to determine the form they use. The System Pumping Record used, but the
the local Board of Health or other approving authority within 14 days from the Pumping m' check with your
accordance with 310 CMR 15.351, must to submitted to
p p ng date in
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 1 4 Pc},)
key to move your Address
cursor-do not
use the return
key, City/Town 1-1 A _
state-___
_t
2• System Owner: Zip Code
1
l
Neme
m.va
Address ss(if different from location)
Clty/Town _
State
Zip Cod
Telephone Number
B. Pumping Record
1. Date of Pumping -�a
Date 2. Quantity Pumped:
3. Component: Gallons
❑ Cesspool($) Septic Tank
❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
If Yes,was It cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
l h (�
Name
gemmice Pump' Vehicle License Number
lhain Co.,inc_
Company
North Reading,MA 018,44
7. Location where contents were 6§e8;
<,
Signature OfTfiiuler
Date
Slsnnturo of 1-160elving Facility(or attach facility receipt) Dgt9
t5form4.doc•11/12
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