HomeMy WebLinkAboutSeptic Pumping Slip - 466 WINTER STREET 10/13/2016 \_o Commonwealth of Massachusetts
City/Town of No Andover
RECEIVED
System Pumping Record
Form 4 NOV I ?()'fib
DEP has provided this form for use by local Boards of Health. Other forms may be �t pe
information must be substantially the same as that provided here. Before using this form, c` 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 sd ........
..................... .............
key to move your Address
cursor-do not
use the return
key.
City/Town State Zip Code
2. System Owner-
............. ........
Name
---------------------------------------- ---------
Address(if different from location)
CityfTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping .......... 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) XSeptic Tank ❑ Tight Tank ❑ Grease Trap
F-1 Other(describe): . ....... .. ........
4. Effluent Tee Filter present? ❑ Yes /No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed cqndition of component pumped:
6. Sys eBy:
_'_
Name Vehicle License Number
Stewa eptic 58 So Kimball St Bradford Ma
rt7s --
..........
......
Company
1
7. Location where contents were disposed:
20 so „ill.s bradford ma
ignature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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