HomeMy WebLinkAboutSeptic Pumping Slip - 53 OLD CART WAY 3/5/2012 Commonwealth Of Massachusetts
--- City/Town of No andover �m�
System Pumping Record RECEIVED
Form 4
DEP has provided this form for use by local Boards of Health. Other rms may be used, but th
0D I ith your
Y y provided y � �,.. ��.. .'
local Board of Health to determine the form the h use The S stem Put"& w t mined to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
us out
forms
e the tab 1. System Location:
on the computer, y J ... ..... 7
key to move your Address
cursor-do not No Andover Ma 01845
City/Town State
use the return - --- ---
- ------------- Zip Code
-----
key.
2. System Owner: p
Name — — --
etum
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping gate --- 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) "Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — —
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: `
6. Syse1 P
umped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Lo tion,,where contents were disposed:
S wart's _re-treatment Plant, 20 So. Mill Bradford, Ma 01835 _
Sign e of duler --------- Date ---,
ip ;.
e of Receiving Y
Facilit Date""
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