HomeMy WebLinkAboutSeptic Pumping Slip - 29 CHERISE CIRCLE 10/12/2016 Commonwealth of Massachusetts
City/Town of No Andover
RECEIVED
System Pumping Record
Form 4 NOV 14 2016
DEP has provided this form for use by local Boards of Health. Other form sTffi*UeN4#0C lb&tWER
information must be substantially the same as that provided here. Before usWWMW*KT6*&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 CIVIR 15.351,
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab Q ...............................
key to move your Addressd
Cursor-do not
use the return . ......
key. City/Town State Zip Code
2. System Owr)er-
Name
return
Address(if different from location)
..........
Cityfrown State Zip Code
---- ... . .......
Telephone Number
B. Pumping Record
1. Date of Pumping Date ......... 2. Quantity Pumped: -�allons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): .................
4. Effluent Tee Filter present? ❑ Yes W No If yes, was it cleaned? ❑ Yes [b No
5. Observed condition of component pumped:
...........
6. System Pumped By:
--------.........
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where nt we ed:
20 so mill st br or a-
...... --- -----
X,
.........
Sig rrou<rof Hauler 6e'te
Signature of Receiviii Facility r- ttach facility receipt) Date
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