HomeMy WebLinkAboutSeptic Pumping Slip - 288 FOSTER STREET 10/14/2016 Commonwealth of Massachusetts RECEIVED
City/Town of No Andover NOV
System Pumping Record TOWN Oi
Form 4 HEAL.TH DE`iATMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do ()- I, -urn the return not AR& -(fr. -------
key. CityfTown State Zip Code
2. System Owner:
rob w_
------- ..........
Name
ferun
Address(if different from location)
.
' ...........
' - __--'"' _ . -_ '"
d ty[Town State Zip Code
Telephone"Number
B. Pumping Record
1. Date of Pumping Ab ua ntity Pumped: ............ .
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
No
4, Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? F❑-1 Yes El
5. Observed condition f omponent pumped:
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6. System Pumped By-
...............
i Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disp ma
'V
20 so mill st bradford ma
..... ...
Signature of Hauler l Date
Signature of Receiving Facility(or attach facility receipt) Date
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