HomeMy WebLinkAboutSeptic Pumping Slip - 453 FOREST 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 be submitted to
I r
the local Board of Health or other approving authority within 14 days fro in
accordance with 310 CIVIR 15.351.
1. 6 Nib
A. Facility Information
Important:Wher)
filling out forms 1, System Location:
on the computer,
use only the tab q5511.- F6-f-
key to move your Address
cursor-do not
use the return - -----------
key State Zip Code
2. System Owner:
tab
............
Name
rauxn
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date_ 2. Quantity Pumped:
Gailons
3. Component: ❑ Cesspool(s) ❑eptic 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 Aped:
6. Syste P -mpeo'By:
Nam g Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st"��o d
Sig at e of Hauler Date
- -.. .............
Signature of Receiving Facility(or attach facility receipt) Date
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