HomeMy WebLinkAboutSeptic Pumping Slip - 400 WINTER STREET 12/8/2016 Commonwealth of Massachusetts
City/Town of No Andover
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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 Pu st be submitted to
the local Board of Health or other approving authority within 14 days gd - g udate in
accordance with 310 CIVIR 15.351.
U 6
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A. Facility Information
Important:When
filling out forms 1 System Location:
on the computer,
use only the tab lloo— -------
key to move your Address
cursor-do not
use the return . ........ ...............
key. City/Town State Zip Code
2. System Owner:
Name
renew
Address(if different from location)
City/Town State Zip Code
Telephone N u—mb e r-
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 compongpt pump
..........
6. Sys mped B
ame Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 s mi st Pfadford ma
Signature ;Hlauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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