HomeMy WebLinkAboutSeptic Pumping Slip - 15 LONG PASTURE ROAD 10/19/2016 <V'\ Commonwealth of Massachusetts
City/Town of No Andover RECEIVED
System Pumping Record NOV 14 2016
Form 4 TOWN OF N URMANDOVER
DEP has provided this form for use by local Boards of Health. Other forms may lb ' dpbMWENT
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 I- L5 1.-.- ----- ............K�_'_
key to move your Add
cursor-do not (7) -
use the return
key. City/Town State Zip Code
2. System Owner:
Name tJ
'Address(-if different from location)
a,tyfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping tol— 2. Quantity Pumped:
[late Gallons
3. Component: ❑ Cesspool(s) P-1 eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? El Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
........................
6. System Pjjmped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where c6ri'tents were disposed:
. ...... ........
20-so-mill st bradford ma
J11 jo j
Si gnat (�e au, D ate
Signature of Receiving Facility(or attach facility receipt) Date
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