HomeMy WebLinkAboutSeptic Pumping Slip - 263 JOHNSON STREET 10/20/2016 Commonwealth of Massachusetts
RECEIVED
City/Town of No Andover
System Pumping Record
Form 4 NOV 1 4 ❑16
TOWN 01"NOR f H ANDOVEiR
DEP has provided this form for use by local Boards of Health. Other forms may bet TJ!WfAMWENT
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 A .............
key to move your Addre$s
cursor-do not trdnvt
use the return ' r-
............................
key. City/Town State Zip Code
2. SysteT Owner:
-- ' a............ ........... ..........
Name
Meru n
.................-----------------------------
Address(if different from location)
City/Town State Zip Code
Tetephone Number
..........
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date G Ilan s
3. Component: El Cesspool(s) 0 '
-9eptic 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 condition of component pumped:
------------
6. System Pum oed y:
..........16, cel I
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
C o m p any
7. Location where contents wereditposed:
/I/o
-—--
20 so mill st 4br � o,,,d ma -------
signs e of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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