HomeMy WebLinkAboutSeptic Pumping Slip - 147 JOHNNY CAKE STREET 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 CMR 15.351. RECEIVED
k. Facility Information UL U U d ZO 16
Important:When TOWN 0 NUR ANuUVER
filling out forms 1. System Location: IiEAUM[)UIARTMEN'r
on the computer, 4y
use only the tab
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
olr-� 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
.............
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
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. Observed condition of component puT
,ped:
---------------
6. System Pumped
Name -vehicle,License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1