HomeMy WebLinkAboutSeptic Pumping Slip - 514 WINTER STREET 12/8/2016 Commonwealth of Massachusetts
W City/Town of No Andover
System Pumping Record
Foirm 4
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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 f
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
A. Facility Information ULL U 8 2016
Important:When
filling out forms 1. System Location: Tow
on the computer, C.( I„„tLpJ�j DUr RTw 0,1"t
use only the tab
key to move your Address
cursor-do not
use the return a._____�
key. City/Town State Zip Code
2. System Owner:
ran L
(y)
Name
nnsn _
Address(if d"Afferent from location)
-----------
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �� 2. Quantity Pumped: 4_11nsmm m-
3. Component: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ---
4. Effluent Tee Filter present? 21 Yes No If yes, was it cleaned? LLI Yes ❑ No
5. Observed Observed condition of corn 4"one n�t pumped:�
�rvp
6. System Pump d-B "
.f FS
Name V Vehicle License Number
Stewarts Septic 6 zy-K�imball 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
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