HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 79 LACY STREET 6/19/2025 Commonwealth of Massachusetts^�ff� '' of
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Record °v� � �D��
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Form 4
Lle
QEP has provided this form for use by local Boards of Health. Other forms may be used, buR 'Me
u�inforrnodonnnuotbe substantially the same as that provided here Before using this form, check vvithyo
local Board of Health \o determine the form they use. The System Pumping Record must be submitted to
the |Oc8| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCyWR15.351.
A. Facility Information
Important:When
filling out forms 1. Svaham Location:
on the computer,
use only the tab
key 0o move your Address /
uusor-donn« �~
use the return -----------------'
key. City/Town ��m�--------------- a�,c�6�------------'
2 System Owner:
VQ
----------------_____________ ---
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` No.Andover MA State-_-____-______
Cityrrown
Zip Code
� _ '==ph"o"n e N u r n be
B. Pumping Record
1. Date ofPumping 2. Quantity Pumped. Gallons
-~
3. Component | | Cesspool(s) XSeptic Tank || Tight Tank [l Grease Trap
1 1 Other(describe):
4. Effluent Tee Filter present? [l Ye o |f yes, was itcleaned? || Yes No
5. Observed condition of component pumped:
---
O. S
Vehicle License Number
maFe--'-~=--- ----------------------'
Stewart'a Septic 58-8 _Ki b || St, Bradford,MA
Com
pany
7. Location where contents were disposed:
20 SoMill St,,Bradford,MA
Signature of Hauler Date
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