HomeMy WebLinkAboutSeptic Pumping Slip - 149 SUMMER STREET 2/14/2017Commonwealth of Massachusetts
City/Town of No Andover
System Pumping Record
Form 4
ECE V
:03 1 4 `1011
TOWN tih: riuKi H ANIXA/ER
HEALTH DEPART: ENT
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.
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key
System Location:
,d(-19
Cftv.AC).
City/I-own State Zip Code
2. System Owner:
-Ta n
Name
((-›
Address (if differentro location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
L
Date
3. Component: LI Cesspool(s)
0 Other (describe):
Quantity Pumped:
Septic Tank
SO-1)
allons
El Tight Tank 0 Grease Trap
4. Effluent Tee Filter present? 0 Yes IIE No If yes, was it cleaned? Li Yes Lil No
5. Observed condition of component pumped:
4,0'1)1
Stewarts Septic 58 So imball St Bradford Ma
Company
7. Location where contents were disposed:
so mill st b ford ma
'g ature of Haule
gnature of Receiving Facility (or attach facility receipt)
CZ"
Vehicle License Number
Date
Date
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