HomeMy WebLinkAboutSeptic Pumping Slip - 120 HAY MEADOW ROAD 12/8/2016 Commonwealth of Massachusetts
City/Town of No Andover
System Pumping Record
wV..... 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 from in
accordance with 310 CIVIR 15.351. 6
A. Facility Information
Important:When TOWN U-NURaH, ANDOVER
filling out forms 1. System Location: HEALTH DFIARIMENT
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return
key. CityfTown State Zip Code
2. System Owner:
Name
rcrEan
Address(if different from location)
----------- .....................
CityfTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 6w 2 Quantity Pumped: Gallon6 5
; '-
3, Component: ❑ Cesspool(s) [A- eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ------------------4. Effluent Tee Filter present? ❑ Yes K1`Ko--` If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
-----------
Name Vehicle License Number
-Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
,,----20-so mill stbradfoj.d- ...........
ler Date
Signature o 4�
----------------
Signature of Receiving Facility(or attach facility receipt) Date
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