HomeMy WebLinkAboutSeptic Pumping Slip - 19 BRADFORD STREET 10/12/2016 Commonwealth of Massachusetts
City/Town of No Andover
System Pumping Record RECEIVED
Form 4 N
DEP has provided this form for use by local Boards of Health. Other forms may be u�qq,,Put the
information must be substantially the same as that provided here. Before using this form',,,.. 'ebk wi,th`ybUr_'R
local Board of Health to determine the form they use. The System Pumping Record must be E'dbmkiedt6
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, a6——�*d�
use only the tab
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
tab
Name
moon
Address(if different from location)
............
City/Town State Zip Code
felephone-Number
—
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Galdn
3, ❑ F]
Component: Cesspool(s) rj§eptic Tank Tight Tank El Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? El Yes r 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 contents were,disposed.
2y.so mill st bradford Mp;7
Sig. to b'f,Hbuler Date
-Signature of Receiving F-aci-lity(or attach facility receipt) Date
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