HomeMy WebLinkAboutSeptic Pumping Slip - 19 OLYMPIC LANE 10/17/2016 Commonwealth of Massachusetts RECEIVED
City/Town of No Andover
M)v q)
System Pumping Record OV"W
Form 4 T
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Lo ation:
on the computer, 7 if1, � . ......
use only the tab
key to move your Addr
cursor-do not
use the return -------
key. CityfTown State Zip Code
2. System Owner:
Name
tetrnn
---- ........
Address(if different from location)
----- ........
Cityf'Fown State Zip Code
Telephone Number
----------------
.......-------
B. Pumping Record Quantity Pumped:
1. Date of Pumping Date El Grease Trap Tight Tank El Gallons
T
3. Component: Cesspool(s) Septic ic T ank El
❑ Other(describe): -------- .............
e s No If yes, was it cleaned? El Yes El No
4. Effluent Tee Filter present? Ej Y
5. Observed condition f component pumped:
-------------------- ........... .........
6. Sys Pu �d By�j
1),m . -- I------------ -----------------
Name Vehicle License Number
Stewarts,Septic 58 So Kimball St Bradford Ma
Company
7. Location here contents were dis s-ed:
20s I st -radfar
Signature of Hauler Date
signature4-Receiving Facility(or attach facility--receipt) —Date--
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