HomeMy WebLinkAboutSeptic Pumping Slip - 23 GILMAN LANE 12/8/2016 Commonwealth of Massachusetts
City/Town of No Andover
System Pumping Record
Foirm 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
A. Facility Information
Important:when 8 H A,rq�)()VER
filling out forms 1. System Location:
on the computer, HEAL'Di
use only the tab ....... -------------
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
VQ
Name
reflxn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1 Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) �epfic Tank ❑ Tight Tank ❑ Grease Trap
El Other(describe): .......
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes F-1 No
5, Observed condition of component pumped-
---------- -------
0 -
6. System Pumped By'
Name Vehicle
License Number
Stewarts Septic 58 So /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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