HomeMy WebLinkAboutSeptic Pumping Slip - 115 VEST WAY 5/30/2017 <1
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 Reco
.Opt be submitted to
d
the local Board of Health or other approving authority within 14 days fror date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Locatioq.,
on the computer, SA
use only the tab
I I I --V '
key to move Your Address
cursor-do not No Andover
use the return ----—----—---------------------------------
key, Cityrrown State Zip Code
2. System Owner:
4A
Name
..................................................
Address(if different from location)
- -----------
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
e
D A 2, Quantity PumpedGallons:
3, Component: El Cesspool(s) Imo'"Septic Tank El Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? El Yes 0 No If yes, was it cleaned? F-1 Yes [:1 No
5. Observed cqndition of component pumped:
J YXj
6. S umped By:
me Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
. ... ............................. . .....
Si e of Hauler Date
....................
S�lqnature of Receiving Facility(or attach facility receipt) Date
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