HomeMy WebLinkAboutGrease Trap - Boston Chowda - Septic Pumping Slip - 109 MAIN STREET 9/9/2026 Town of
.
NOfth Andover
CMhusefts
III
SEP 14
S itemPumpingRecord
azs
Y
Forte i . .
Health Department
r has Provided this form ..r-.
inform', -. for use by local Boards of Health. Other x - ..Y-
anon musf be sustanai the same forma may be used, but theDEP ---
lo al r - ly as that provided here:=Bef
Bard of Health to determine the form t ore us�n9 th is form, check with ❑
the local Board of they use. The System Pumpin Recur your
Health or other approving authority withi g d must be submitted to
accordance with 31 o CMR _ tY n '14 days from the purrs "in da• - 15.351. p g to in
A. Facill Inform '
tY anon
Important:When ,
filling out forms 1. System Location:
on the computer, �
use only the tab 0 9 f �]
key to move your dress r .
cursor-do not
use return
� ■i ow_ ■�■+ _ .; . ;. A _ •ems _
V w:�i.'+r..r ���T�'.°.•� +�.. �la f r . s r:.F�+h3741.}a.�`iwa ti,.s as y+.#►�G
Y •
T n ,
State
2. S stem Owner. ztp code
Name
star
Address(f different from location) .
CIPWrown =
State
- ?ip.Code
'• - telephone Num r _ ... ..,
B i bar, `• • • 4 f •3 T-
• Pum i n R Rec .,
y � T
. . g � ord l
'. 'l• o Date
f Pumping
Date 2. Quantity Pumped:
`3. Gompon�nt:' L� Dess 1
�(s) � Septic TankOrightGallons
Tank � Grease Trap
L� Other{describe}:
4. Effluent Tee Filter presents El Yes
[1 No If yes,was it cle
aned? Yes 0 No
5. Observed condition of component pumped: .s 3i5piF4 t6 a .ti. �
w a .+y.F a•. �rL R• h#• t2 i.! { r w.. Yr r� r G r a
6. System Pumped By:
Name
Vehicle License Number
Company
7. Loc tion where contents were disposed:
Sign::Z;7o-f Hauler
vote
Signature of Receiving Facility(or attach facility recei t
A) Date
t5foIrm4.doce 11/12
• S]$tem Pumping Record•Page I of I
i