HomeMy WebLinkAboutSeptic Pumping Slip - 511 WINTER STREET 12/8/2016 _ Commonwealth of Massachusetts
u 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 must be submitted to
the local Board of Health or other approving authority within 14 days fRrWVF0g date in '
accordance with 310 CMR 15.351.
A. Facility InformationTf R
Important:When _
filling out forms 1. System Location: HEN�,�
computer,on the
use only he tab i ❑ ,
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
VQ
Name
lEIfNR
Address(if different from location)
City/Town Stake
Telephone Numb r
B. Pumping Record
~ �allons__
1. Date of Pumping ..pate � 2. Quantity Pumped: ❑ --......
3. Component: ❑ Cesspool(s) LI Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes dNo If yes, was it cleaned? ❑ Yes ❑ Na
5. Observed condition of�cgmponent mped;
6. S s e '8y;
Name Vehicle License Number
Stewarts Septic 58 So Kirn all St Bradford Ma
Company _..._
7. Location where Conte is were disposed:
20 so mill st I radfa ma
-- -.. _..__ _ — —
/ j .
S nature of Hauler 4- Date
nature of Receiving' g Facility(or attach facility receipt) Date
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