HomeMy WebLinkAboutSeptic Pumping Slip - 108 WINDKIST FARM ROAD 1/9/2017Important When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
CommonweaIth of Mt r 3e0usetts
City/Town of
System Pumping Record
Form 4
EC E
JAN 0 9 ai
TowN OF ANIDOVER
HEALTH DEPAIUMENT
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 CMR 15,351.
A. Facility Information
1,
System Location:
(A) 4td
Ad71/)( 11/"\ AIA ([1(62.1
City State Zip Code
2. System Owner:
Name
vr`,
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Component:
State Zip Code
6t) crr) _2-3516'
Telephone Number
I vi
Date
El Cesspool(s)
CI Other (describe):
2. Quantity Pumped:
C3 Septic Tank
El Tight Tank
Gallons
0 Grease Trap
4. Effluent Tee Filter present? Er Yes E] No
5. Observed condition of component pumped:
6.
Company
If yes, was it cleaned? 0 Yes 0 No
yetem Pumped By:
10V-1,-e1 PhAiliii\r
€rprs
Location where contents were disposed:
Vehicle License Number
A,P/LeA.A/
SipSlgn,tufe oftleul�r
Signature o t.Iv1ng Facility (or attach fadilty receipt)
Date
Date—
taforrndl.doc• 11/12
System Pumping Record • Page 1 of 1