HomeMy WebLinkAboutSeptic Pumping Slip - 2189 SALEM STREET 10/28/2011 - Commonwealth of Massachusetts
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City/Town of No.Andcver � �
y tern Pumping Record °t� cur �:t i �i o1� i�i r����i
IT rri i i AR��irf, IIa
Form 4 ,
DEP has provided this form for use by local Boards of Health. Other forms 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 1. System Location:
forms on the
po.
ka4
only the tab key Adclress — ❑e.
l
to move your No.Andover Ma 01845
cursor-do not ---- -- -- -- --- --- - -- --
use the return City/Town State Zip Code
key. 2. System Owner:
Name
emm Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) QISSeelptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - - —
�a
4. Effluent Tee Filter present? ❑ Yes 12, No If yes, was it cleaned? ❑ Yes ��o
5. Condition of System: /� ❑ —
6. System Pumped By:
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 Recei g 'acility Date
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