HomeMy WebLinkAboutSeptic Pumping Slip - 10 CHERISE CIRCLE 10/7/2016 Commonwealth of Massachusetts
City/Town of No Andover
RECEIVED
Symf4m tm Pumping Record NOV I 1�
For
TOM(R��Ltfo,t
DEP has provided this form for use by local Boards of Health. Other forms may be HN
3 (jour
information must be substantially the same as that provided here. Before using this form, At'R'rw' ii'
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 -------------------------
key to move your Address
cursor-do not
use the return ............... .
key. CityfTown State Zip Code
2. System Owner:
Name
rsrrn
.................................................. ........
Address(if different from location)
......................... -------------- -
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 16-it-
Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 1xSeptic Tank F-1 Tight Tank ❑ Grease Trap
❑ Other(describe): --------------- - -----------......................--------—-------------
4. Effluent Tee Filter present? ❑ Yes YNo If yes, was it cleaned? ❑ Yes 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 co t ere dis
20 so mill st bra a
Signet Hauler f Date
Signature of Receiving Facility(or attach facility receipt) Date
t5forrn4.doc•11/12 System Pumping Record•Page 1 of 1