HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 12/8/2016 Common' wealth of Massachusetts
City/Town of No Andover
System Pumping Record
Foirm 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 CM R 15.351.
RECEIVED
A. Facility Information
Important:When nil)
filling out forms 1. System Location: TOWN(N-NUN,6 H iv�JuOVER
on the computer, (,-,
use only the tab �A)_j
KALTI-i I)EPAR rveg
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
li
2. System Owner:
C
Name
Address(if different from location)
City/Town state Zip Code
Telephone Number
B. Pumping Record
A/ k,
1. Date of Pumping Date 2. Quantity Pumped. Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No 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 disposed:
20 so mill st bradford ma
Signature of Hauler Date
- -- vlF--'-------t---------- ----" ------'§lgnature of Ve�eg aciiity(or attachfacility receipj Date
t5form4.doc-11112 System Pumping Record•Page 1 of 1
Commonwealth ofWassachusetts
City/Town of No Andover
'System Pumping Record
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. RECEIVED
A. Facility Information U M6
Important:When "'OM OF ANEX)VE1
filling out forms 1. System Location: HU1111
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
rob
2. System Owner�_
Name
7
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Callan
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
-—----__.______.____--
Signature
_ 7`i_ oCH-a-6ler —------- Date
_Signature of ReceivingFacility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of No Andover
System Pumping Record
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. RECEIVED
A. Facility Information
Important:When ol-NUK�H pj,q�)()VER
filling out forms 1. System Location: TCi
on 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:
VQ
------------------
Name
reuxrt
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallon
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? F-1 Yes ❑ No If yes, was it cleaned? F-1 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 disposed:
20 so mill st bradford m
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11112 System Pumping Record•Page 1 of 1
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City/Town of No Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards cfHealth. Other forms may be used, but the
information must be substantially the same ax 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 |000| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CK4Fl 15.351.
RECEIVED
A. Facility Information U BZ016
Important:When
filling out forms 1. System Location: ANDWER
vnmecomputer, TMENT
use only the tab
key vo move your Address
oumv, do not
use the return ------- ---------���-----
key. City/Town State Zip Code
2. G
Name
--
Address(if different from location)
City/Town State Zip Code
T�ophonnNum&*
B. Pumping Record
1. Date ofPumping Date l Quantity Pump ed:
3. Component: El Cesspool(s) [j Septic Tank El Tight Tank El Grease Trap
�]
Other(describe):
4. Effluent Tee Filter [l Yee El No If yes, was it cleaned? R Yes El No
5. Observed condition of component pumped:
G. System Pumped By:
wumo Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford M
Company
7. Location where contents were disposed:
20 so mill otbradfnrd ma
s|unumu,ovHauler Date
8ign*neofRe;�i�ngpaoi\ity(mauwch-facility�cei�) oate
`
u5funn4.dmc~11/12 System Pumping Record^Page 1 of 1