HomeMy WebLinkAboutSeptic Pumping Slip - 1077 OSGOOD STREET 10/26/2016 Commonwealth of'Massachusetts RECEIVED
------ . City/Town of No Andover
7
NOV 14 2016
System Pumping Record TOWN Oh NUR 11-1 ANDOVER
Form 4 HEALTJJ[iPPARTMENT
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.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, '�J
use only the tab --vo —05o' ------
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
OQ2. System Owner:
-
,V10- Name
------------------------
Address(if different from location)
City/Town State Zip Code
-—
-----------
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: M
—A
Date Gallons
3, Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank E:94ease Trap
❑ Other(describe): ------------------------
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed gondition 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 disposed:
20 so mill st bradford ma
3A!nn—w��—
i riat of Hauler Date
sigrIatureo—fReceiving Facility(or attach facility receipt) Date
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