HomeMy WebLinkAboutSeptic Pumping Slip - 23 WILLOW RIDGE ROAD 12/8/2016 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. RECEIV
A. Facility Information [411 (T8
Important:When
filling out forms 1. System Location:
on the computer, � 1-11 ) TOWN(A NUH�HiAM.)(OVEF",',
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lEv
use only the tab
-A ,
key to move your Address -kjull--
cursor-do not
use the return
key. CityTFown State Zip Code
Z. System Owner:
rab VI(Y
Name
-;�ddre—ss"(fFcFT4-e--r'e-n""t"-"f'r--o-m--—loca—tion) ----'--
City/Town State Zip Code
Y�Iej��ho e-N-u-m—ber
B. Pumping Record
1. Date of Pumping J 2. Quantity Pumped: '
allons
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. Observe� condition of component pumped:
6. System Pumpe
Name Vehicle License Number
Stewarts Septic a8-So,,j<im ball St Bradford Ma
Company
7, Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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