HomeMy WebLinkAboutSeptic Pumping Slip - 173 RALEIGH TAVERN LANE 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.
RECEIVED
A. Facility Information DI-C U 8 M16
Important:When
filling out forms 1. System Location: 'TOWN 0� W)W H ArWOVER
on the computer, HEAL11 I XPARTMENT
use only the tab
key to move your Address
cursor-do not
use the return
key. ity/Town State Zip Code
2. System OwTer:
Q
V
V( T",
Name
Address(if different from location)
CityfTown State Zip Code
'T-e-1'eph'-'o"-ne Nun--her
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date ail
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
V I
4. Effluent Tee Filter present? F] Ye'/L-4 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
-------------
6. System Pumped
..............
-------------------
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
Signature of Receiving Facility(or attach facility receipt) Date
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