HomeMy WebLinkAboutSeptic Pumping Slip - 1320 Osgood St - 10-25-2024 - Septic Pumping Slip - 1320 OSGOOD STREET 10/25/2024 ^
Commonwealth m� Kd Massachusetts
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System Pumping Record
Form 4
DEp has provided this form for use by |uoo| Boards of Health. Other forms may be used, but the
information must be substantially the same a8 that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCyNR16.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key m move your ^ouream w
oursor-donm
use the return
key. City/Town State— Z-
Code
2. System Owner:
VQ
Name
Address(if different from location)
No Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date GaT91S
3. Component: E] Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? F If yes, was it cleaned? Yes No
S. Observed condition of co nen� d
70
S. System Pumped By:
.
,aL
Name 1, Vehicle License Number
Shawa ' S i 8SoKimball S 8rodfondK0A
Company
7. Location where contents were disposed:
20Go [Ni|| S1 Bradhzrd K8A
Signature of l4guler Date
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