HomeMy WebLinkAboutSeptic Pumping Slip - 283 CAMPBELL ROAD 10/13/2016 Commonwealth of Massachusetts
City/Town of No Andover RECEIVED
System Pumping Record NOV 'i i ?01(i
Form 4 TOWN%N(J'' f A NUOVER
DEP has provided this form for use by local Boards of Health. Other forms may be u�eAj bunt-[eP\I'M E II
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 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 City/Town State Zip Code
key.
2. System Owner:
SC
Name
rzuun
--, - " ---------------- .. ....... ----—------
Address(if different from location)
ity/Town State Zip Code
..........
Telephone Number
B. Pumping Record
I
1. Date of Pumping tiv-- ,, 2. Quantity Pumped: S—D C-3--
- U
Date Gallons
3. Component: E, Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? El Ye No If yes, was it cleaned? El Yes El No
5. Observed condition of component pumped:
6. System Pumpe B
l_ �
........... .
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler Date
............
Signature of Receiving Facility(or attach facility receipt) Date
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