HomeMy WebLinkAboutSeptic Pumping Slip - 59 PADDOCK LANE 10/13/2016 Commonwealth of Massachusetts
City/Town of No Andover RECEIVED
System Pumping Record Nuv
Form 4
0+
DEP has provided this form for use by local Boards of Health. Other forms may be usedvbot ev''1/1 F'�NO-NI
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.
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A. Facility Information
Important:When
uls'e m1. System Lo tion-
e omputer,only the tab id 0('-'A<" ..........
............... .... .
Address
key to move your .City/Tow
cursor-do not
Use the return 'y 'W State Zip Code
rye
key.
2. System Owner:
f(1-
-41,
name bs
---------------------—---------------- ........
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
e d
1. Date of Pumping A
Date Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ;Septic Tank F-1 Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? F-1 Yes ❑ No
5. Observed co7d' ion of component pumped:
6. Sy to Pu ped
Name Vehicle License Number
.Stewarts Septic 58 So Kimball St Bradford Ma
Company
IV,
7. Location where contents wer disposed:
20 so mill st b ord n)61
Signature of Hauler Date
...........
Signature of Receiving Facility(or attach facility receipt) Date
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