HomeMy WebLinkAboutSeptic Pumping Slip - 83 WILLOW RIDGE ROAD 10/21/2016 RECEIVED
<ZN Commonwealth of Massachusetts NOV 14 2016
City/Town of No Andover •OWt4
System Pumping Record HFAUH L, "`A6
Form 4
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.
A. Facility Information
Important:When
filling out forms 1. System Location:
an the computer,
use only the tab
key to move your Address
Cursor-do not
use the return ................... -----------
key. City/Town State Zip Code
2. System Owner:
tsb
e-
Name
enrn
-- ------------------
Address(if different from location)
................ -----------
CityrTown State Zip Code
Telephone--N—uni-b--er
B. Pumping Record
. C.
1. Date of Pumping Date 2 Quantity Pumped: Gallons
3 Component: El Cesspool(s) M Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 414 If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
——-- -------
6. System Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disp9s
20 mill s radford ma
. ..........................
Signature of Hauler Ile, Date
—----------
Signature of Receiving Facility(or attach facility receipt) Date
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