HomeMy WebLinkAboutSeptic Pumping Slip - 263 JOHNSON STREET 10/20/2016 (2) T"\ Commonwealth of Massachusetts RECEIVED
City/Town of No Andover
NOV
System Pumping Record
Form 4 TOM u� ti(
liEAJH t,,ENT
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.
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A. Facility Information
Important:When
filling out forms 1. System Location
on the computer, y c
-—-----------
use only the tab
...............
key to move your Addrqss
cursor-do not
use the return "I ('1_._h�i0 _V ___1r- ____ ----------
key. City/Town State Zip Code
2. System Owner:
ran 1�
Name
reran
Address(if different from location)
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City/Town State Zip Code
Telephone Number
B.' Pumping Record
1. Date of Pumping 2. Quantity Pumped:
I Gallons
3. Component: ❑ Cesspool(s) D-°Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ...............
4. Effluent Tee Filter present? ❑ Yes 2/No If yes, was it cleaned? F-1 Yes ❑ No
5. Observed condition of component pumped:
6. System Z
Rtlm d By:
Name Vehicle License Number
Stewarts Se is 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so ml I I s br'a"`d_
ford:�a,.
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Si gf re of Hauler Date'
Signature of Receiving Facility(or attach facility receipt) Date
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