HomeMy WebLinkAboutSeptic Pumping Slip - 97 WINDKIST FARM ROAD 10/21/2016 Commonwealth of Massachusetts RECEIVED
rp City/Town of No Andover
WN
P System Pumping Record
Form 4
A
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, Cl " - f
use only the tab 1417--vu- in3- -kus
key to move your Address
cursor-do not
use the return .-
key. CityfFown State Zip Code
2. System Owner:
Name
rerxvn
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Address(if different from location)
.... ..
CityfTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
bate Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 4"Screptic Tank El Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? El Yes F4,-1 16' If Yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. SysteT,P?mp d By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20o-mill.st,bradford ma
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'SigInarWWRauler r Date
Signature of Receiving Facility(or attach facility receipt) Date
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