HomeMy WebLinkAboutSeptic Pumping Slip - 61 WHITE BIRCH LANE 10/7/2016 Commonwealth of Massachusetts
City/Town of 'No Andover RECEIVED
System Pumping Record N01V I ?(jj 6
Form 4
TOINN
DEP has provided this form for use by local Boards of Health. Other forms may bb�usod b4t t hjq,--WF'
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
key to move your -Address
cursor-do riot
use the return .......
key. City/Town State Zip Code
2. System Owner:
VQ
C Q /
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Name
Address(if different from location)
City/Town' State' Zip Code
Telephone Number
B. Pumping Record
00
2. Quantity Pumped: ------
1. Date of Pumping Date -da-116ens - -
3. Component: ❑ Cesspool(s) [8-'Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 56 No If yes, was it cleaned? ❑ Yes No
5. Observed condition of component pumped:
--- ---------...... ..................
6. System Pumped By:
0or
00 --10
Name Vehicle Lice'Kse Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where cont is were di5pos
20 so mil
-------------- ------------—--------
Signature of aule'r Date
Signature of Receiving Facility(or attach facility receipt) Date
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