HomeMy WebLinkAboutSeptic Pumping Slip - 483 JOHNSON STREET 12/8/2016 Commonwealth of' Massachusetts
City/Town of No Andover
System Pumping Record
Form 4 RECEIVED
DEP has provided this form for use by local Boards of Health. Other forms n-l6�,6e%1ajW4 the
information must be substantially the same as that provided here. Before using this form the �
h with your
local Board of Health to determine the form they use. The System PumpiNgVFWd6 witted to
I e in
the local Board of Health or other approving authority within 14 days from t I e
accordance with,310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 0 X) ("4-)r ...............
key to move your Address
cursor-do not
use the return ---------- ---------------------key. City/Town State Zip Code
2. System Owner:
rah
Name
Address(if different from location)
.... ----------------
CityfTown State Zip Code
05,
Telephone Number
B. Pumping Record
1. Date of Pumping A Quantity Pumped: -Gallons 0
3. Component: F1 Cesspool(s)- e-ZSeptic Tank [:1 Tight Tank ❑ Grease Trap
❑ Date
Other(describe): ---------------
4. Effluent Tee Filter present? F-1 Yes No If yes, was it cleaned? n Yes ❑ No
5. Observed condition of comp g�ent umped:
%?S i� Puml"e
................
Na l
Stewarts Septic 58 So Kimbo I St Bradford Ma Vehicle License Number
Company
7. Location where contents were disposed:
so mill st ma rd f bra ra f rd ma
Si ature of Hauler Date
- -------------
)Signature of Receiving Facility(or attach facility receipt) Date
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