HomeMy WebLinkAboutSeptic Pumping Slip - 597 FOSTER 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 must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.3511. RECEIVED
A. Facility Information DU3 0 8 Z016
Important:When I'
1. System Location:
filling out forms ' OWN N
O� UR H� ANDOVER
on the computer, I J, HEALTI-i DUM-WENT
use only the tab
key to move your Adddrs,
cursor-do not
use the return —-—------
key. City[Town State Zip Code
ran 2. Syste Owner:
Name
Address(if different from location)
—---------
CityfTown State Zip Code
Telephone Nurnber--
B. Pumping Record
-"-- --) 6
I. Date of Pumping 1-1- -- 2. Quantity Pumped:
Date Gal ons
3. Component: ❑ Cesspool(s) [J/Septic Tank ❑ Tight Tank El 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. S stem Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
'210's 8 7st bradford ma
O
�AS!ah�a rre of Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date
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