HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 400 SHARPNERS POND ROAD 4/2/2025 �r� r� �m��
����M�M7��yl\A/�'��|+F° rf ��������[�����LJ����ffs |W./// u| mw|u|Andover
r�
��
��^ f|Iy/ | K�\A/[l ^�/ No Andover
tA
Pumping
Record ��Y
��y��t�>�� u K�����K���� '~~'
Form
OEP has provided this form for use by local Boards ofHealth. DthevbfnaA4 UePadMWt
information must be substantially the same as 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 31OCyNR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab lee,
key m move your *noeen
cumor-uonot
me ret
urn
um key. _'lT'—
SEate----------- Zip CoueVQ ��
_ System Owner:Name
Address(if different from location)
No Andover M8
City/Town State Zip Code
Telephone Number
B. Pumping Record
qll'()-&5�7- 2. Quantity Pumped:
1. Date of Pumping Datel Gallons
3. Component: Cesspool(s) M,SepticTonk D Tight Tank E] Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Fl Ye�uNu |f yes, was itcleaned? Yes Fl No
G. Observed condition of component pumped:
' ^
-. -'_
tpn-2j4mped By:
ame �7ehicle License Number
Septic 8o Kimball St Bradford yNA
Company
7. Location where contents were disposed:
20 SoMill S df rd K8A
4 4 W- �
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5mrn4.uuc-11/12 System Pumping Record^Page 1uf1