HomeMy WebLinkAboutSeptic Pumping Slip - 240 RALEIGH TAVERN 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 Pn tn&,P=d must be submitted to
the local Board of Health or other approving authority within 14 d ping date in
accordance with 310 CIVIR 15.351.
A. Facility Information
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Important:When HEALI
filling out forms I System Location:
on the computer,
)avef n
use only the tab
key to move your Address
cursor-do not
use the return
key. CityfTown State Zip Code
2. System Owner:
raA
Name
reuxn
----------
Address(if different from location)
Cityf'Fown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping J/ 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank F-1 Grease Trap
❑ Other (describe): -----------------
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
...............................
6. System P sped By:
Name Vehicle License Number
Stewarts Septil 58 So Kimball St Bradford Ma
Company
7. Location where co ents,were disposed:
20 so mill st bra rd ma .............
1(0
Signature of ler Date
. ............ ---------
Signature of Receiving Facility(or attach facility receipt) Date
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