HomeMy WebLinkAboutSeptic Pumping Slip - 400 SHARPNERS POND ROAD 5/24/2016 Commonwealth Of Massachusetts
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System Pumping Record
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DEP has provided this form for use by local Boards of Health. WAyt Aped, but the
information must be substanfiially the same as fihat provided here. i iI`�form, check wit,
local Board of Health to determine the form they use. The System Pumping Record must be submi
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Faci@ty Wormation
Important:When
filling out forms 1. System Location:
on'the computer,
use only'he tab
key to move your Address —_—
cursor-return not
use the ret North Andover
key. City/Town
. ... Slate Zip Code
VAQ2. System Owner.
Name – . _.._. .._.
Address(if different from location)
ity/T own
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping tate` - `'q uantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank
❑ Tight Tank ❑ Grease Tra
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was ii cleaned? ❑ Yes
❑ No
5. Condition of System:
6. System Pumped By:
—
Stewart's Septic Service Vehicle License Number
Company —..._.... .
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
Signature of Hauler
Date
Signature of Receiving Facil ty
Date ........
._. _.
t5form4Aoc•03/06
System Pumping Record-Page