HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 457 BOSTON STREET 8/3/2022 Commonwealth of Massachusetts
City/Town oaf No.Andever
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System Pumping RecordForm 4
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DEP has provided this forms for use by local Boards of Health. Other forms may be used, but the
information must be substantially the sarne as that provided haere. Before using this farm„ check with your
local Board of Health to determine the form they use. The System Dumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 1 a1.
A. Facility InformationImpo _.. ._._ .....�.__ ,... .._., ...
g out f When1. System Locaatiom
on the computer,r,
use only the tab t
key to move your Address
cursor-do not
use the return
key cityrrow n State Zip Code
2. System Owner:
Address (nf differ°ens scorn lra<nrtiorai
No.Andover MA
tw i town' State Zino Code
f`e ephnone Number,
B. Purnping Fe+ �ord_..�___�_.�...mm......_... ._. ..___._-__w__
1. Date of turn Datepin0 �t� 2. Quantity Pumped- �0
Component: [ Cesspool(s) Septic Tank Tight Tank Crease Trap
C.._' Other (describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes �u J No
5. Observed condition of component pumped:
. Systern pumped By:
(24 c'n, .
Narne Vehicle License Number
Stewvart's Septic 58,So Kimball St. „ Bradford„MA
tortpc",any
7, location where contents were disposed:
20 SoMill St.,Bradford,MA
&mature of Hauler bate
r natcare rat ke_ � Facilu cervin y . _. ..,
£J ty (or aatt�cWa faac;iVlt recur t t��ate
t5f'ornA.doc- 11112 Systeai Purarpinff Record•Pepe 1 of I