HomeMy WebLinkAboutSeptic Pumping Slip - 81 LACONIA CIRCLE 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 M't' U 8 ?016
Important:When
filling out forms 1. System Location: TOVVN
on the computer, 0
use only the tab .............
key to move your Address
cursor-do not
use the return
key. CityfTown State Zip Code
2. System Owner:
Name
few i' `
Address(if different from location)
-Cityf"rown State Zip Code
- - -----'———feleph oneN u mb er
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date +�a I�Ion Is
3. Component: ❑ Cesspool(s) Septic Tank -"hf-TaaL- ❑ Grease Trap
Other(describe): -—---------------
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition f component pumped:
6. System Pumped
By:
Name. Vehice License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma -----------1------------
Signature of Hauler Date
-------------
Signature of Receiving Facility(or attach facility receipt) Date
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