HomeMy WebLinkAboutSeptic Pumping Slip - 467 SALEM STREET 12/8/2016 ^
Commonwealth nf �� �
�/[]�l[M(]�l\8/�}��/u / ^// '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 nr other approving authority within 14 days from the pumping date in
accordance with 310CMR15.351.
RECEIVED
A. 8�:�«�~K^�v« KD��^������~��0i
, ~ Facility Information—~~ U/P U 8 V816
Important:When
filling out forms 1. System Location: TOWN U-NUN/n*NDOVER
on the computer,
use only the tab
key mmove your Address -
ournor-oonm
use the return --------- ---------- ----------��------
key. citnTown State Zip Code
2. System Owner:
Name
Address(if different from location)
C�y�own State Zip Code
Telephone Number
B. Pumping Record
1. Date ofPumping ----��'~=^�-c��--- 2 Quantity oo�� � � Gallons
3. Component: Fl Cesspool(s) Septic Tank Fl Tight Tank El Grease Trap
. `
[]
Other(describe):
4. Effluent Tee Filter present? [I Yes D No If yes, was it cleaned? Yes No
5. Observed condition ofcomponent pumped:
8. System Pumped By:
Name Vehicle License Number
5tewada Septic 58 So Kimball S Bradford Ma
Company
7� Location where contents were disposed:
20 so mill atbnadfo,d ma
Signature mHauler Date
Signature m Receiving Facility(or attach facility receipt) Date '
t5f orm4.doc-11/12 System Pumping Record-Page 1 of 1
`