HomeMy WebLinkAboutSeptic Pumping Slip - 53 MARIAN DRIVE 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 I.. days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information RECEIVED
Important:When
filling out forms 1 System Location: [JEC,' U 8 2016
on the computer, 5-71
use only the tab
fow
key to move your Address JJEAUM DEPARTMENT
cursor-do not
use the return ——----------
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from—location)
---------------.1---1-------
0----------_
n State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
b�ite 'Pallons
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 Pum
Name Vehicle License Number
Stewarts Sept7ic8 So Kimball St Bradford Ma
Company
7. .Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler Date
Signature-afiReceiving Facility(or attach facility receipt) Date
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