HomeMy WebLinkAboutSeptic Pumping Slip - 295 FOREST STREET 12/8/2016 Commonwealth of Massachusetts
ECEIVE,D
City/Town of o Andover
System Pumping Record
tiud' U 8 2016
Form 4
TOWN U. H A„)OVER
DEP has provided this form for use by local Boards of Health. Other forms mw-fialjwd�NAN6
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.
A. Facility Information
Important:When
filling out forms 1. System LocatloT.--
on the computer,
use only the tab _--------- -—----
key to move your Ad s
cursor-do not
use the return C.ityfT-ow-n_ State Zip Code
key.
2. System Owner:
raa ...........
Name
rekun
Address(if different from location)
Cityfrown State Zip Code
YeilephoneNumber_
B. Pumping Record
❑� o
1. Date of Pumping Date Quantity Pumped:
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0--�No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
-—-------------- ------------
6
Syl
Vamer Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Comp�_ny__'_____
7. Location wWe contents were disposed:
20 so (idl b dfor a ��__
§i6na"iure of Hauler bate
Signature Receiving Facility..(-or—attach facility receipt) Date
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