HomeMy WebLinkAboutSeptic Pumping Slip - 201 CARLTON 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 U[_C' U 8 2 016
Important:When
filling out forms 1. System Location: J'OW��()p,-t&h i H M uOVER
on the computer, C lriEN-'[Fi[)EFAr\1'MUJ
use only the tab co
key to move your Address
cursor-do not
use the return _U OVC -------
key. City[Town State Zip Code
2. Syst e Owner:
�
9_ Name
� r
_Address Tff_&A&ent from location)
CityfTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quarj�ity Pumped:
Date Gallons
rg',/
3. Component: El Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ----------------- --------
4. Effluent Tee Filter present? ❑ Yes El No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed copdition of component pumped:
6. S Pp pe By:
T/
eh
Vehicle-
tcle License Number
Stewarts Septic 58 So Kimball St-Bradford'Ma
Company
Qa tion where contents were disp
s6_ IIF b
natur Date
Signature of Receiving Facility "F-ittach facility receipt) Date
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