HomeMy WebLinkAboutSeptic Pumping Slip - 125 ROCKY BROOK ROAD 10/20/2016 <C\.. Commonwealth of Massachusetts RECEIVED
City/Town of No Andover
NOV I ml(i
System Pumping Record -rowr
Form 4
HE 111,1 D.
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, cl
use only the tab
key to move your Addr
cursor-do not
use the return 7as &oeje',� ......... —-----
key. City/Town State Zip Code
Oki 2. System 0 ner:
Name
------------
Address(if different from location)
- ---------- -----------------------.. ...............
City/Town State Zip Code
Telephone Number
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B. Pumping Record
1. Date of Pumping 16 Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): ............
4. Effluent Tee Filter present? ❑ Yes Na If yes, was it cleaned? ❑ Yes F-1 No
5. Observed condition of component pumped:
6. 'Sysffl Pump� yj 'C'
Ir
A ( , ( pvt�j
I- 7C j
me Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Cornpany
7. Location where contents were disposed:
20 so mill st br8d,forda ma
/6
Signa ure of Flce r Date
..........
nature of Receiving Facility(or attach facility receipt) Date
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