HomeMy WebLinkAboutSeptic Pumping Slip - 378 SALEM STREET 6/23/2016 6
Commonwealth ®f Massachusetts
RECEIVED
City/Town of No Andover
System Pumping Record
6 Form 4 1,0W114()F��1,40R TH,,,,j,,1F)(7A/ER
DEP has provided this form for use by local Boards of Health. Other torms may be used, but the
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 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 378 Salem St —-----
key to move your Address
cursor-do not No Andover MA
use the return ____----------
key. City/Town State Zip Code
2. System Owner:
tab
Kahn ——------
Name
tetum
-Address(if different from location)
----------- -------------
City/Town State Zip Code
Telephone Number
B. Pumping ec®r
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes Pfr No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Syster B y
Name Vehicle License Number
Stewart's Septic Service
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 Facility Date
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