HomeMy WebLinkAboutSeptic Pumping Slip - 1935 SALEM STREET 12/9/2016 <CN Commonwealth of' Massachusetts
City/ "own of No Andover A')
5'�
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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 4-7-
use only the tab
k---E
key to move your Address,
cursor
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
ria6c4 C . .......
14� Name
Address(if different from location)
---—----------------- -----------
CityfTown State Zip Code
Telephone Number
B. Pumping Record
c
--j-z' 14�
1. Date of Pumping Date 2. Quantity Pumped.
Gallons
& Component: ❑ Cesspool(s) P<Septic Tank ❑ Tight Tank ❑ Grease Trap
El Other(describe): —---------
4. Effluent Tee Filter present? F] Yes90 If yes, was it cleaned? ❑ Yes P,No
5. Observed cyndition of component pumped:
)�'� 4 6 —
6. System Pumped By:
3 3 ,9
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company were, isp�
7. Location where contei )se'd-
f.
// 1 01
20 so mill st br " '/ /I I
❑
�Zy
5 12-
Signb re of Ha or Date
Signature of Receiving Facility(or attach facility receipt) Date
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