HomeMy WebLinkAboutSeptic Pumping Slip - 57 CHRISTIAN WAY 12/8/2016 Commonwealth of Massachusetts
City/Town of No Andover
w System Pumping Record
M
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 day 'ng date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When 'TOWN a�
fining out forms 1. System Location: I-g 4.1 i C ``�°� I�
on the computer,
use only the tab 7
key to move your Address
cursor-do not
use the return
key. City/Town State — Zip Code
2. System Owner:
Q Z LAJ 3❑_�.__ ........._._._..__._._.______
Name
�enm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B Pumping Record
1. Date of Pumping Da e 2. Quantity Pumped: (ilon: _......
3. Component: ❑ Cesspool(s) m 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 pumped: j
& System Pumped B -
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
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